Concierge Medicine Is Not Understood

Concierge medicine is not well understood. As Dr. Centor states, “Policy wonks have ignored this movement for too long. Retainer medicine is a fast growing start-up industry. It grows because it fills an unfilled niche.” Many people and companies are beginning to utilize concierge doctors more frequently and it will continue to grow as our current system continues to languish in its broken state of greed and corruption.

There are some questions that need answering and I will strive to give some answers.  There is an organization named the American Academy of Private Physicians (AAPP), which encompasses the physicians operating in the concierge medical community. The American Academy of Private Physicians and was founded in 2003. Some areas on the site are for membership only but most are viewable by the public.

Within the concierge community, there are a few large groups serving people on a regional scale. What is unique is that when combined with a high-deductible medical insurance policy to cover hospitalization and some other high dollar costs, the model is significantly more cost effective for the patient. At present, there may be some setbacks in coverage, but eventually the medical insurance industry will innovate and cover more of the present holes. I am sure that there is talk between the AAPP and medical insurance to do this.

The one item I have not found that may be a total out of pocket expense for some is prescriptions. High deductible insurance policies will not fill this gap at present. For some with chronic illnesses or diseases requiring expensive medications like diabetes, this could be expensive.

To this point I have been using one term for roughly four types of service. Dr. Centor defines the first three and Dr. Matthew Mintz talks about the fourth. I quote both of them for maintaining clarity.

We need to define terms:

Concierge medicine – paying a large (>$3000/yr) fee to contract with a physician (usually an internist) to provide same day appointments, phone access, email access, comprehensive and continuous care

Retainer medicine – paying any fee to receive the same access as concierge medicine. Generally concierge practices have smaller panels, i.e., the more you pay, the less patients the physician has to follow

Direct primary care – retainer medicine for a lower fee

Boutique medicine - I think the key words in this definition are “specialized” “stylish” and “elite.” The first word is something commonplace in medicine, but the later two words are something usually not associated with medical practice. “Luxury” is also implied in the word “boutique.” Thus, in my opinion, a boutique doctor is one that specializes in unique, often luxurious services, that are not offered by others and which will therefore cost a little extra. Read the full blog here by Dr. Mintz.

I am bothered a little with Dr. Mintz and his concern for ethics and word association. The current medical system is broken and needs overhaul. If I could afford any of the above, I would be there in a heartbeat. I say let the patient decide what level of service he/she desires and can afford. If a doctor establishes excellent doctor patient relationships, he will have a great practice. If a doctor is this concerned about the meaning and connotation of a word, maybe medicine is not where the doctor should be.  Many doctors writing about this topic are stressed about ethics.  I think too many decades of fighting with the insurance industry and government has addled their thinking.  I remember the 1940s and 1950s when this would not have been a concern.  Even before this, we had fee for service, but not the term concierge.  Some doctors were paid with produce and other patients paid with currency.

We as patients cannot always afford the best in care now and are seeing too many cases of government euthanasia because they won't pay for the treatment. See my blog here about the treatment of kidney transplant patients being denied immunosuppressants by Medicare. I predict that if the current system does not have a jolt soon, many patients will not have a place to get care, regardless of the cost.

Our medical insurance industry needs to change and if these types of services can exist without insurance, we may be better off. Hospitals are better able to demand more money from the insurance companies and major medical will become more affordable as some companies are forced out of business for their greed. Insurance executives do not need million dollar plus salaries. As a patient I feel that changes are coming and the patients may do better as a result. Will everyone be happy? This is highly doubtful, and some will suffer as a result of these changes.

Another helpful article on concierge medicine can be read here. This article highlights some of the professional jealousy by doctors and specialists unable to make the change. Insurance companies are angry and have dropped doctors. HHS is also warning doctors. Some states are investigating whether under the insurance laws in their states this is even legal. Read this article with care.

"If Medicare continues to tighten the screws on doctors ... some will react by saying, 'I'm just fed up with the whole thing.'" And if more doctors shift away from traditional practices to concierge medicine, it could exacerbate the physician shortage because there will be fewer doctors to go around. I hate to say this, but this may get action, both good and bad, from the voters when our congressional people refuse to act to get government out of medicine.

Patients have had it too good for too long and will become militant if Congress refuses to act and wait times for appointments become longer and longer.

I must add this Medscape article of May 27.  This is what we need, doctors that are not afraid to speak out and are not intimidated by doctors that are striking out because they think the "system" is the only way.  I found this article very good. 

Some Explanations and Venting

I like comments on my blog from others. I also appreciate the emails I have received from those that email me from my profile page even more as this allows for a better interchange of ideas. I do become annoyed by most of the advertisers that attempt to sneak comments through. Some are becoming very adept at this until I back check the link provided or back check the name on the post. I like that the delete key works as easy as it does at times like this.

Unless I use the product or have reliable information about at particular product, I seldom promote a product in a blog. I may promote a type of product without a specific brand being mentioned when there is good evidence of relative equality among brands. I do this because then it is an individual preference as to which brand a reader chooses. Most also go with what the doctor recommends if a prescription is required.

Most of the comments I have received lately have been spam. Saturday, I had one that looked authentic; however, upon further examination and a little correspondence, I found out that the site is a dummy site operated by a public relations person looking to make a sale for some of his clients. I have no idea about the product and whether it will work as advertised. Plus, under the circumstances of the exposure to the product, I will not even try it. Too good to be true – usually is. Plus these products most often do not deliver what their advertising claims. I will keep my money thank you.

Do I like receiving all this spam? Not a chance! As long as the delete key continues to do its thing, I will not hesitate to use it to keep spam off my blog.

Then I receive emails that are what I consider the ultimate in poor taste. They are from people that I term “ambulance chasers.” They want to know if a family member or I have used a medication or a list of medications. If we have, they want to help us obtain compensation for possible injury received from the medication. I will never use them as to-date; I have not used any of the medications on their lists. Plus I will never use a firm that comes looking for work, as they generally want a greater percentage of any amounts received. I prefer talking to a local attorney and having a recommendation for a firm. Occasionally, the firm of record is the only firm that may be used and then you may not have options.

I have also been receiving requests for guest posts. I may as well say it now. I will not allow guest posts from commercial companies or firms looking for business. I will not allow guest posts of any type because I like what I am doing. If a product or service is one I have used and like, I will blog about it. If a product or service is something that I don't like, I will blog about it. I know I cannot please everyone, and it is not my intention. I want to inform you about diabetes and related issues. Occasionally, I find something that I have an interest in that is not related to diabetes.

Should We Standardize Diabetic Medical Tattoos?

When will doctors stay out of patients personal lives? Apparently, they feel that it is their duty to run everything when it comes to patients and their personal lives. This time doctor, stay in your office and out of our lives. When you diagnose us with diabetes, you say little and expect much. Our appointments are short and not enough time to learn. You cannot live with us 24/7, so leave well enough alone.

This short article in Medscape does get my ire up. This doctor feels that he should have the right to tell diabetes patients where and what is proper for diabetes tattoos. He feels that first responders should have a standard place to look for tattoos as they do for medic alert bracelets. Since this doctor is not a person with diabetes, I hope that he does not get his way.

Many people have abandoned medic alert bracelets and even necklaces for tattoos because they do not want them seen by everybody that meets them. They want something that is there, but not on a wrist. Some people are not allowed to wear bracelets or necklaces because of their occupation. Many people wish to keep their diabetes a secret from others. I wonder if the good doctor has even considered this. Another thought doctor, how many people actually have medical alert tattoos and how many people with diabetes even wear medical alert jewelry?  

Even if this doctor convinces other doctors that this needs to be standardized, I say that the people desiring unobtrusive tattoos will get them. If the doctors think they can make the tattoo artists put all medic alert tattoos in one place, they don't understand what a tip can accomplish. A few will abide by the wishes of doctors, but their competitors in the next bloc will be happy to do it according to the client’s wishes.

Sorry doctor, I think this is one desire for control that is an illusion. I can almost hear this doctor complaining how non-compliant his patients are for not having their tattoos aligned. I am surprised he is not bellowing about the unsanitary conditions and potential for infections with tattoos.

Friday Tidbits 05-25-12

Normally I would do this in a regular blog, but it is becoming so disheartening the way the American Association of Clinical Endocrinologists is not updating the list of approved diabetes resources, that I must entreat them to add a few resources. It seems that a few of those on the current list are getting less traffic now than before they became listed.

Not only are they not listing additional resources, but now they will have to factor in the changes of the American Dietetic Association (past name) to Academy of Nutrition and Dietetics (current name) and their way of taking over the field of nutrition and forcing many in that profession to change to other professional organizations to be able to give nutritional advice to people in need.

I also think if the AACE cannot decide whether there are more websites that they can approve, then it is time to take down the page and stop portraying these as the only approved sites. I know there are other sites that deserve being mentioned and I will continue to visit them. Even professional organizations should act professionally. By not keeping their website vibrant and updated, they are doing a disservice to themselves and their profession. This says nothing about the patients that could benefit from some of the listings.

The site page listing the approved websites became active on September 27, 2011 and has not added another approve site since. Granted, the “experts” are probably busy earning a living, but does it take almost eight months with no additions. I am sorry, but this does not make for good public relations. I will continue to call attention to inaction on the part of the AACE. Endocrinologists should also be reminding their association that more needs to be done to expand the list as this could help them proudly point to the list of approved sites.

This is a very disturbing article to read. I had high hopes for telemedicine and thought it could be very useful in some cases. “In response to concerns about tele-medicine’s effect on patient safety, many states have begun prohibiting physicians from prescribing drugs without conducting a prior physical examination. In fact, more than 30 states have instituted this type of rule since 1998.” Apparently, some physicians and lawmakers do not want this to happen.

The laws in these states mandate that the patient be examined by physician before they can prescribe any drugs. This physical examination requirement (PER) has potential far-reaching effects for future programs. This may also be something that can be expanded to counter act the proposed FDA in their approval of over the counter (OTC) medications. It will be interesting to see how this plays out and if physicians can encourage lawmakers to expand these state laws.

Just the fact that the current regulations are costing lives should start making headlines, but will the news media even go there. This is something that needs attention of more bloggers, medical and patient. Also, read this by Jason Shafrin.

The last item is even bigger that the author may realize. He is talking about accountable care organizations (ACOs) that came into being under the Accountable Care Act of 2010. We should learn in June the possible outcome of these and much more when the US Supreme Court announces their decision. Will we still have ACOs or will they be a thing of the past. There have been many articles about the good and bad sides to ACOs and I chose this as one of the more positive writings

Unfortunately, what many writing about ACOs and like this one about health information technology (HIT) seem to ignore is the fact that health information technology is part of a law passed prior to 2010 to put computers in medicine so this will continue to be with us. Whether we like electronic medical records, electronic health records or other electronic care records, these are here to stay.

What we need is greater electronic security for our electronic medical records to prevent other people from gaining access to them and getting medical help at our expense. Yet this always takes a back seat in any discussion of the pros and cons of medical databases.

What Is Diabetic Neuropathy? - Part 3

This is a quote from this article. “Although the metabolic causes of diabetic neuropathy are perfectly well understood and documented, treatments for this disorder are still limited.” This statement shows that researchers and scientists think they know it all, but studies are still surfacing that can prove them wrong. Some medical researchers are becoming too smug and making statements they should not be making.

Then we have this article that says, “Nearly half of all diabetics suffer from neuropathic pain, an intractable, agonizing and still mysterious companion of the disease. Now Yale researchers have identified an unexpected source of the pain and a potential target to alleviate it.” This is very contrasting. Maybe metabolic causes are understood and it is the neuropathic pain that is the mysterious companion. Regardless, statements like these stand out like the sores they are and create doubts as to whether scientists really understand.

Another quote from the same article even tends to make decisions even more difficult to understand, “How diabetes leads to neuropathic pain is still a mystery,” said Andrew Tan, an associate research scientist in neurology at the Yale School of Medicine and lead author of the study. "An interesting line of study is based on the idea that neuropathic pain is due to faulty 'rewiring' of pain circuitry. With a growing number of diabetics, the condition represents a huge unmet medical need. Once neuropathic pain is established, it is a lifelong condition.”

As much as I detest these statements, we need to realize that authors of studies are attempting to have their research noticed and stand out among all the reports issued on a daily basis. I do not agree that this should be totally necessary and some statements are not that believable as it is, because too many readers of medical science reports have a jaded view caused by statements that are not quite believable.

The study reported by Gretchen Becker in her blog on Health Central covers a potential target for reduction or prevention of the pain caused by diabetic neuropathy and the report can be read here. Yes, this is the second mention, but well worth reading.

Neuropathic pain, whether caused by diabetes or other causes, is still painful and sometimes debilitating, reducing the quality of life for those suffering from it. Since I am one of those people who was diagnosed with neuropathy approximately 10 years prior to the diagnosis of diabetes, it has been a long 19 years with the pain in my feet.

I am glad to see that research is finally beginning to make some progress into the cause and potential treatment for those suffering from neuropathy. I have a tendency to read past the sensationalism promoted the study reports, but at times, I want to scream at what I know to be irresponsible statements.

Final of three parts.

What Is Diabetic Neuropathy? - Part 2

Today, there is no cure for diabetic neuropathy. Optimistically I feel that medicine is closer than before. There is a host of treatments available and some may assist you in reducing the effects of diabetic neuropathy, while others may not help at all. The most effective treatment is maintaining blood glucose levels at or near normal. This seems to be impossible for about 50 percent of people with diabetes, as they will develop diabetic neuropathy.

With the studies still finding other causes, I am a little cautious about the statement that the metabolic causes of diabetic neuropathy are perfectly understood and documented. Treatments are yet still in the infancy state, but several are on the way. First, I will discuss some of the aids to help in reducing the pain and controlling some of the symptoms. Unless people start realizing that they need to manage blood glucose levels, diabetic neuropathy will, like diabetes, continue to get progressively worse.

The blog here by Gretchen Becker also explains part of the reason I am cautious about people understanding everything about diabetic neuropathy. We may be closer, but there is more that we may learn.

There are a few drug-related options as well as physical therapy for controlling pain caused by diabetic neuropathy.

Drug Options:

• Antiepileptic Drugs: these are becoming a common drug for painful diabetic neuropathy. It has important side effects like sedation and weight gain.
• Classic Analgesics: for those with a debilitating chronic pain condition, these drugs can offer immediate relief.
• Trycilic Antidepressants: Very effective in decreasing pain but since the doses must be high for them to be effective the individual can become addicted t the dosage. Cardiac arrests are common when ingesting these drugs.
• Serotonin-Norepinephrine Inhibitors: these are commonly used to target painful symptoms of diabetic neuropathy. They may also help depressive patients.

Physical therapy is the next area for investigation. With medications, physical therapy can help relieve pain and should be used to avoid drug dependency. Certain physical therapies can help alleviate pain, burning, and tingling sensations in legs, feet. Physical therapy may also help patients with muscle cramps, muscle weakness, and even sexual dysfunction.

Then there is electrical nerve stimulation, which is painless (although I can't attest to this), may help those suffering from stiffness. Electrical nerve stimulation may also help foot ulcers heal.

Regular massages or manual therapy involving stretching of the muscles performed by qualified chiropractors or massage therapists will inhibit muscle contractions, spasms, and atrophy due to poor blood supply. Muscle strengthening with specific exercises, such as swimming or even some aerobic exercises will help maintain muscle strength and reduce muscle mass reduction.

A good physical therapist will make sure that exercises for patients with diabetic neuropathy do not hurt their feet, which are usually sensitive. Therapeutic ultrasound is a method of stimulating the tissue beneath the skin's surface using very high frequency sound waves, can help some patients regain sensitivity in their feet. The latter did not work for me, but did for another patient and he had few problems for several years.

Events are unfolding in the world of neuropathy and neuropathic pain. I have two articles of which this is one and holds promise for those of us suffering from neuropathic pain. This medication, which will not be on the US market for several years, will help with neuropathic pain and epileptic seizures. It has been developed in Israel so it will be necessary to have it on the market there before FDA gets it hands on it. This should hold out hope for anyone suffering neuropathic pain.

The second article is about a food product available now by prescription. It is to relieve the numbness caused by neuropathy and restore much of the sensations deadened by neuropathy. This product is not a cure, but a needed bandage for neuropathy and the lack of feeling in your feet and hands. There are some questions that still need answering, as this could be the closest we have come to having a product that will reverse the effects of neuropathy. Read an article about it in the above link, or go directly to their website and read about it. Use the site for contact with representatives if you find a doctor that will prescribe the medication.

The complications of diabetic neuropathy can sneak up very quietly and sometimes be very devastating. So be very careful if you have or are treating diabetic neuropathy. If you lose sensation in your feet, the risk of infections can grow very rapidly if you do not check you feet daily. If you are not able to see the bottoms of your feet, have another family member check them for you, or if this is not possible, get yourself a mirror on a pole that can be used for this task. Get to a doctor if you have a cut that is not healing or a bruise that is not getting better.

Bladder and kidney infections need immediate attention and should be seen by a doctor as soon as possible. Frequent nausea and vomiting can result in poor blood glucose management thereby make the neuropathy worse and you should also see a doctor. The last item is muscle damage or decrease that needs attention by a doctor. Do not let these complications of diabetic neuropathy get the advantage of you, but see a doctor and let the doctor make the decision about what needs to be done.

Next blog is the final of three parts.

What Is Diabetic Neuropathy? - Part 1

Apparently there is more added to diabetic neuropathy recently, and there has been some new classifications added or revised. This article dated May 11, 2012 has some terms I have not encountered recently. Therefore, I think this could be very enlightening for others and especially members of our informal group.

Diabetic neuropathy refers only to people with any type of diabetes. Reading the first sentence only can be misleading. Therefore, I am quoting the conditions and definitions for clarity and accuracy.

“Different nerves are affected in varying ways. Relatively familiar conditions, which may be associated with diabetic neuropathy, include:

• Third Nerve Palsy: When the individual cannot move his eye normally due to damage of a cranial nerve.
• Mononeuropathy: When only a single nerve is affected - the nerve is physically compressed, resulting in a lack of blood supply.
• Amythrophy: Muscle pain due to progressive waste and weakening of muscle tissues.
• Mononeuropathy multiplex: Profound aching soreness regularly felt in the lower back, hips or legs, resulting in sharp loss of sensory function of the nerves. This can slowly develop over a number of years.
• Polyneuropathy: Most commonly, this disorder results in weaker hands and feet, as well as some loss of sensation in the affected areas. Some patients complain of a burning needles-like pain. This disorder occurs when many nerves throughout the body simultaneously malfunction. The patient might step on something that should hurt, but feel nothing. It can appear either without warning or steadily over a long period.
• Autonomic neuropathy: The visceral nerve is affected, which may impact on the heart rate, digestion, respiration, salivation, perspiration, blood vessels, and sexual arousal. This occurs when there is a failure from the heart arteries to adjust heart rate and vascular tone to keep blood flowing continually to the brain. Dizziness or fainting when standing up rapidly is common.
• Sensory motor neuropathy: When sensory nerve loss affects the face; in some cases it may spread to the upper arms.”

Read my blog here for comparison of terms and notice the increase in terms used in this article. I am not sure if some of these were extracted from some of the prior used terms or are new definitions that needed to be explained. Terminology has increased from four to seven.

Recent studies have found that approximately 50 percent of people with diabetes develop diabetic neuropathy. The disturbing part of this is the signs (diagnosed by a doctor) and symptoms (felt by the patient and needs to be told to a doctor) tend not to be experienced for 10 to 20 years after diabetes diagnosis. Even more frustrating is that the majority of individuals with neuropathy symptoms do not realize what is happening until the complications are severe or possibly permanent.

Because of their importance, again I will quote from the article, “Some of the signs and symptoms associated with diabetic neuropathy:

• Numbness, electric pain, tingling and (or) burning sensations starting in the extremities and continuing up the legs or arms
• Heartburn and bloating
• Nausea, constipation or diarrhea
• Problems swallowing
• Feeling full when eating small amounts of food
• Throwing up after a few hours of having eaten
• Orthostatic Hypotension (feeling light-headed and dizzy when standing up)
• Faster heart rate than normal
• Chest pains, which sometimes can be a warning of an impending heart attack
• Sweating excessively even when temperature is cool or the individual is at rest
• Bladder problems - difficulty in emptying the bladder completely when going to the toilet, leading to incontinence
• Sexual dysfunction in men
• Sexual problems in women with vaginal dryness and lack of orgasms
• Dysesthesia - the patient's sense of touch is distorted
• Significant facial and eyelid drooping
• Eyesight may be affected
• Muscle weakness
• Speech impairment
• Muscle contractions"

How is diabetic neuropathy diagnosed? This is where a patient needs to communicate with the doctor when some of the symptoms (more than one) of the above are noticed. The doctor should do or recommend some diagnostic tests before making a definitive diagnosis. The doctor should also ask some very specific questions and the patient needs to answer them honestly.

If your doctor orders an MRI, you should question the validity for doing this as it is not the tool for definitive diagnosis as discussed in my blog here. The doctor may order an electromyogram (EMG). This records the electrical activity in the muscles. The doctor may also request a Nerve Conduction Velocity test (NCV). This test records the speed at which induced signals pass through the nerves. Both are excellent definitive tests and less expensive than an MRI.

During the physical examination, the doctor will check your ankle reflexes, for loss of sensation in your feet, changes in skin texture and color, and for a sudden drop in blood pressure when you stand up from the prone position. The doctor may also use the filament test and the vibration test to check for loss of sensation.

Next blog will cover treatments and complications.

Neuropathy Causes

Just because you have diabetes, does not mean that you will develop neuropathy. And, if you have peripheral neuropathy does not mean you have diabetes. Yet time and time again, these are touted as being facts and even medical guidelines want us to believe this. Experts want us to believe this and my blog here shows where this is headed by the types of tests they want done if they think someone has neuropathy.

To this I say B.S.. I have been searching the web for more explanations and I have now found two articles that I believe give more meaning to neuropathy, causes, and treatments. I will refer you to my blog here, where I discuss the types of neuropathy. I also have four more blogs on different parts of neuropathy in the days following the first blog. I will have three more blogs on diabetic neuropathy following this one.

Now to discuss the causes of neuropathy. Although not mentioned specifically, smoking is a risk factor for peripheral neuropathy. Why so few sources do not mention this is unknown; however, most do advise stopping smoking as a treatment because of the damage it can do to the nerves. About 30 percent of neuropathy is idiopathic, meaning they are of unknown causes and about 30 percent of neuropathy is due to diabetes. The remaining cases of neuropathy are called acquired neuropathies and have the following possible causes:

Trauma or pressure on nerves, often from a cast or crutch or repetitive motion such as typing on a keyboard.

Nutritional problems and vitamin deficiencies, often from a lack of B vitamins. 

Alcoholism, often through poor dietary habits and vitamin deficiencies,

Autoimmune diseases, such as lupus, rheumatoid arthritis, and Guillain-Barre syndrome,

Tumors, which often press up against nerves,

Other diseases and infections, such as kidney disease, liver disease, Lyme disease, HIV/AIDS, or an underactive thyroid (hypothyroidism),

Inherited disorders (hereditary neuropathies), such as Charcot-Marie-Tooth disease and amyloid polyneuropathy,

Poison exposure, from toxins such as heavy metals, and certain medications and cancer treatments,

And metabolic disorders.

While this list may not be totally inclusive, it does account for about 40 percent of neuropathy cases. So if you have neuropathy, there are many possibilities to choose from and diabetes may not be the culprit. If you have diabetes and do not have neuropathy, keep it this way with tight management of your diabetes.

I would also point out that often people with diabetes can have the second item of vitamin deficiencies mentioned earlier and this can lead to neuropathy, especially deficiencies of Vitamin B1 and B12. I have urged people before to have these tests done to have a baseline for reference as soon as a diagnosis of type 2 diabetes is made. This in turn will aid your doctors in proper diagnosis of neuropathy if it develops later. If your vitamin B's are okay then the neuropathy may be caused by your diabetes. Conversely, if you are deficient in Vitamin B1 or B12, maybe you neuropathy is not diabetes caused. Many physicians will not do the tests, but will declare diabetes as the cause of the neuropathy.

I feel that this article and this one are good reading for education about neuropathy. At least then you will have a good understanding of the types and causes of neuropathy. You will know when someone says they have diabetic neuropathy, they may or may not be correct in their assumptions unless they have had the tests and know that it is diabetes caused. I had my neuropathy about 10 years before my diagnosis of diabetes and at the time my neurologist said it was caused by smoking. Right? Probably, but there may have been other reasons behind it.