That is a direct quote from the oath Dr. Pacheco and I took upon receiving our medical degrees from Brown Medical School. I am pretty sure that most of the other players in the health care debate did not. Many are in it for the profit primarily, as has become apparent by the course our system of health care has taken in this country.

The latest news, as of 8/24/10, is that we at Primary Care Partnership have decided to be more proactive with respect to health care reform. We are disappointed that the Obama administration’s efforts at meaningful legislation in this arena have produced so little change to date. As far as we can tell, healthy physicals will be paid for by Medicare in the new year, and very little else will change. Private insurers are being required by law to allot a greater proportion of the premium dollar to patient care, but premiums are still sky high and climbing.

Apparently, private insurers are arguing that “patient care” should include their costs associated with prior authorizations. “Prior auths” are one of our pet peeves, and have been since 2003, when we dropped AETNA and CIGNA because of their insistence that we spend a significant amount of our time convincing hired “reviewers” of the medical justification for our choices of tests and treatments for our patients before they would authorize payment. We believe this practice delays and obstructs the care of our patients. Moreover, unknown third parties should not wield that kind of authority, not do they deserve access to our patients’ private records.

Since that time, the major private insurers, including BCBS, Harvard/Pilgrim and Tufts have come to require prior authorizations, as well. We have tried to continue working within their networks, as they represent most of our patients’ coverage. When we have objected to those things that take us away from our patients and require that we fax and phone, wait on hold and petition for permission we have been told it’s “just a little admin function,” and directed to websites intended to facilitate these things.

Recently, we had a typical experience with Harvard/Pilgrim that has triggered a series of thoughtful reviews of our predicament. Despite hours of effort by our nurse and practice manager to obtain authorization for a patient to get a chest CT as requested by the radiologist who read her chest Xray and found a mass, we kept being denied. The online system failed, the human beings who back it up acknowledged the legitimacy of the request but were unable or unwilling to give us authorization. Finally, I had to request a physician-to-physician review, at which point the hired doctor immediately authorized the test, saying that the same thing had happened often enough that he suspected it was a case of a mass on Xray that needed a CT.

So, after adjourning a meeting of all the staff of PCP one afternoon after this episode, we gave our notice to Harvard/Pilgrim that we are terminating our contract with them. The same H/P representative to whom we had appealed the prior authorization mess seemed surprised we would do such a thing. We explained that our discontent includes their insistence on using confidential coding information for reasons other than claims submission, as well as failing to compensate us commensurate with the extent and complexity of work required in the care of our Harvard/Pilgrim patients. In other words, we feel they are paying just enough to do as quick and dirty a job as possible, with no pay at all for the considerable extra staff time their “admin functions” require. And it is we who hold the ultimate liability for the result, and we who are asked by such a system to compromise our best work.

None of this will be news to those who have followed the health care debate closely. We cannot stop the insurers from doing these things, but we can leave the network, or “vote with our feet.”

We are among those who believe in the primacy of the doctor/patient relationship. Payment models should support and encourage it, not compromise it, so as we leave off participation in those networks we feel do not permit us to put patient care first, we will invite our established patients to stay the course with us. If you have an HMO plan, we suggest you consider switching to a PPO plan, if possible. If not, request one be offered. It will allow you to go out of network for your care and be directly reimbursed after the fact. Familiarize yourself with your rights and freedoms under your plan. You may be surprised to find that your HMO provides no out of network coverage at all, and that is putting too much control in the insurer’s hands, we believe.

We are people taking care of people. Insurance is just one way of paying for that service. The doctor-patient relationship should come first.

What this all means for our Harvard/Pilgrim patients is that by the effective date of termination, 12/30/10, we will ask for payment in full at the time of service from the patient. We will assist with coding information so that the patient can submit a claim to directly to H/P. Reimbursement to the patient will be according to that person’s terms and conditions of coverage. Many other small practices have resorted to this approach to remaining independent. The alternative is to abandon the small practice model we believe allows us to do our best work and join a big group, where providers typically see 40 patients a day.

We hope you are with us. We ask anyone considering leaving our practice for financial reasons to speak to Kathy Lord, our billing manager, first.

Cindy Corriveau appointed to Brown Medical School faculty

We are pleased and proud to announce that our RN, Cindy, was recently appointed clinical instructor in family medicine at the Alpert Medical School of Brown University. For the past ten years, Cindy has generously added instruction of our many students and trainees to her busy schedule of responsibilities at PCP. She is a gifted teacher, tirelessly researching current topics and challenging diagnoses in the medical literature, bringing fresh information to her practice as our director of clinical staff. In her capacity as teacher she has helped students pursuing many levels of training, including medical assistant, nurse practitioner, and medical doctor. She most enjoys her direct patient care duties, and makes sure that the advice she gives is well-supported and evidence-based. She teaches by example, as well, demonstrating care and compassion in all that she does, and treating each person she encounters, be it patient in need, coworker, scheduling clerk, or insurance representative (and this can be quite taxing!) with respect. She is noted for her unparalleled ability to assume the best of those with whom she interfaces in the course of her work day, thereby bringing out the best in all. We are quite happy to celebrate this noteworthy accomplishment with Cindy, and look forward to following her academic career in addition to working with her in Westport.

Commonwealth Choice

Under the Massachusetts Health Care reform law, insurance companies now offer specific insurance plans for affordable health insurance for uninsured individuals. These plans are offered under the name of Commonwealth Choice. Each insurance company has instituted Commonwealth Choice plans and selected the providers who may accept the plans. Low income individuals may be eligible for the subsidized Commonwealth Care plans. Additional Information.

HPV testing

You may have seen recent advertisements on television about testing for Human Papilloma Virus. There are also kiosks at the mall and orange rubber bracelets with the logo "right to know" on them referring to the same thing. HPV is the causative agent of cervical cancer, and there is now a patented DNA test that can be done at the time of your Pap smear, to detect the presence of the virus. At Primary Care Partnership we perform the Thin Prep Pap smear, processed at Southcoast Hospital. If an abnormal smear is discovered, the HPV test is performed automatically. Results are always called to the patient if positive. If negative, we inform our patients by letter, with any recommendation for follow-up care. An abnormal Pap smear, HPV positive, may signify precancerous or cancerous changes of the cervix. A referral to a gynecologist is made at that time, and a culposcopy is usually done there to determine whether treatment to eradicate the virus and restore normal cellularity is needed. The company that markets the HPV test is urging all women over the age of 30 years to demand that HPV testing be done at the time of their pelvic exam/Pap smear. The reason for the age recommendation is that, under the age of 30, many spontaneous remissions of HPV positivity to negative occur without intervention. The American College of Obstetrics and Gynecology has yet to issue a consensus statement on the advisability of universal testing over 30. Until it does, we are making the test available to all of our patients, and will continue our current practice of receiving HPV tests on all abnormal Paps as before.

Please familiarize yourself with the complex issues surrounding the discovery of HPV and its potential implications for your health. A good initial resource is the US Government Center for Disease Control in Atlanta. Go to www.cdc.gov. There you will also find current information on the newly approved vaccine against HPV, Gardasil, now recommended for males and females aged 9-26.

New American Heart Association Guidelines

As of Spring 2007, new AHA guidelines have been released, recommending a brisk 30 minute walk every day for every woman, at every stage of life as the best prevention against coronary artery disease and heart attacks. Women with even borderline high blood pressure or an unfavorable cholesterol profile are urged to treat them aggressively if even 1 other coronary artery disease risk factor is present: smoking, diabetes, previous heart disease, or a family history of heart disease. Stress with spasm of the coronaries was identified as a particularly worrisome factor in women, so active measures to reduce stress are also important. Barbara Smith, licSW is here to help with counseling where needed, but simple practical tools to mitigate physiological effects of stress are also available.

Researcher Aggie Casey at MGH instructs her patients to take “2 minute vacations” during the day. She describes these as deep, diaphragmatic breaths, in through the nose then, with pursed lips, out through the mouth while thinking “I am...at peace.” Her studies have shown that this simple measure can significantly lower circulating levels of adrenaline, heart rate, and blood pressure, de-stressing the heart.

2 minute vacations also reduce stimuli to the adrenal glands, so that production of cortisol, the chronic stress hormone, is reduced. This, in turn, helps prevent deposition of fat around the waist, a clear correlate of cardiac risk, and the bain of most middle-aged women.

If you have been in for your yearly health maintenance exam, you have probably already learned about the AHA guidelines. Please make them a priority for this year and beyond. If stress is an issue, please consider massage with Sarah Snyder, acupuncture with Kristin Boudreau, and Yoga with Karen Moore Holliday. Best advice yet: listen to your “inner voice.” It will tell you what you need!

Food for Thought: Vitamin D and Wheat Gluten

One of the fat-soluble vitamins (A,D,E,& K) vitamin D is naturally best absorbed through the skin. Sunshine is our optimal source, but those of us at risk for skin cancer are best advised to avoid direct sunlight and use sunblock, which prevents D absorption. For this reason, and also because we in New England live in the Northern hemisphere where the weather often blocks the sun, an oral supplement may be needed.

It is possible to measure vitamin D levels in the blood. You may have been notified of a low level, and advised to take more. We measure the 25 OH (hydroxylase) form of the vitamin, as it best assesses overall activity. Previously, a blood level of 10-60 ng/dl was deemed adequate. In response to recent research, target level has been increased to 30-100 ng/dl, a big change. In our experience, since beginning to test our patients last year, many patients fall in the deficient range.

In addition to known activity as an aid to absorption of calcium (recall that severe vitamin D deficiency causes rickets) recent studies have demonstrated a much greater likely role for vitamin D. It is now believed it may be involved in autoimmune disease, thyroid function, depression, fibromyalgia, arthritis, and heart disease. Specific research is looking at the connection between vitamin D and multiple sclerosis.

Assuming a normal diet and at least some natural exposure to sunlight, most women are well advised to take an additional 800 IU per day of vitamin D. The form known as “D3” or cholecalciferol is apparently best absorbed orally. In the event of an acute deficiency (level of 16 or less) we may recommend a higher, prescription level. Care must be taken, however, to avoid toxicity or secondary too-rapid calcium accumulation. Retesting after a period of replacement is prudent.

Because sunscreen effectively blocks vitamin D, we have begun to propose to patients considering only applying sunscreen between 10 AM and 4 PM, so that some D can get through. Apparently, 10-15 minutes of exposure translates into 10-15,000 units of D, so that is still the most efficient way to get the vitamin D we need. Depending on skin type and cancer risk, however, even this limited amount of exposure can be damaging. We can help you decide.

Wheat gluten deserves some attention. I have begun to counsel select patients to consider a trial of gluten avoidance in the diet. It seems that for certain predisposed patients, ingestion of wheat gluten (the protein in wheat) may trigger inflammation in the GI tract. That, in turn, starts a cascade of events resulting in inflammation and autoimmune activity. Target tissues may include joints, thyroid, skin, brain, in addition to the GI tract itself. A low blood level of vitamin D may be the first indication. Eliminating gluten seems to be associated with fairly rapid reversal of symptoms in these areas, as well as more normal metabolism in patients  struggling either to gain or to lose weight. I have a patient who experienced an 8 pound loss in the first month off gluten.

A typical gluten-sensitive suspect would be an overweight middle-aged woman suffering from irritable bowel and arthritis. Gluten avoidance means looking at the ingredients on your food labels and substituting gluten-free choices for those foods listing wheat, gluten or wheat gluten on the label. Celiac disease represents a severe form of gluten sensitivity, associated with malabsortion and diarrea. Those patients must avoid all gluten to feel well, but many of us may feel a lot better with relative gluten avoidance. Ironically, those attempting to “eat right” by adding whole wheat may be adding extra gluten.

Physical signs of possible food sensitivity include rough skin on the upper outer arms, a horizontal crease across the middle of the nose, stuffy nose, or extra creases under the eyes. Of course, many foods are potential offending agents, and testing, although imperfect, is available when an elimination diet doesn’t seem to work. (Please be aware that much of this advice is based on clinical anecdotal observation, as opposed to systematic scientific research.)