It is easy to think that substance use can't affect us - until it does. Substance use disorder does not discriminate and should not be shamed or shunned.  It is a disease just as much as diabetes or asthma.  That is why Dr. Delaporta offers substance use disorder treatment as part of her primary care practice.

Like other chronic illnesses, there are medications available to help with substance use disorder.  Opioid use disorder is the over use of or addiction to things like vicodin, percocet, oxycodone, heroin, or fentanyl. Buprenorphine-naloxone (brand name suboxone) has been well established as a very helpful part of promoting recovery for people with opioid use disorder.  There are also medications that can help people with alcohol use disorder.  Medications like oral or injectable naltrexone (brand name vivitrol), acamprosate (campral), and disulfiram (antabuse) have been proven helpful in recovery from alcohol overuse. ​

​Just when we thought Amazon had already conquered all the industry spaces, they have recently come out with a new health offering.  According to their site’s tagline, they can “quickly treat common conditions with 24/7 video visits and messaging with a clinician. Upfront pricing. No appointments, and no insurance needed.” Sounds a lot like Direct Primary Care, doesn’t it? Or does it!?

Wow… this was unexpected! Almost a year ago, Lifespan and Care New England, along with Brown University, announced a proposed merger. At that time, I wrote a blog about why this was such a horrible idea. While the physicians at Direct Doctors completely understood the downsides of such a merger, especially in this small state, we did not think Rhode Island would get this right! Well today, the Attorney General denied the merger while at the same time an FTC advisory board voted 4-0 to file a joint lawsuit to do the same. While news organizations are calling this “stunning,” this is likely only because we tend to get these decisions wrong all the time. There is not necessarily anything stunning about realizing that having one organization in charge of 80% of inpatient care in a state is a bad idea! It seems obvious to us, given the mountain of evidence that AG Neronha cites, that health care monopolies cause prices to go up, access to go down without any appreciable change in care. 

    Now, Rhode Island still has a long way to go to fix our broken health care system. We need to focus more on primary care including incentivizing more primary care physicians to practice here. We need to give innovative practices (like Direct Primary Care) more of an opportunity to thrive. We have to work on giving patients more choice while also lowering costs. We are doing that here at Direct Doctors and will continue to do so as we grow in the future. ​

Dr. Ashley Lakin DO is "over the moon" to be starting her own branch of Direct Primary Care with the help of her friends at Direct Doctors.  Dr. Lakin, trained at Brown with Drs. Turshen & Hedde.  As a fellowship trained Maternal-Child Health Family Physician, Dr. Lakin is excited to add prenatal care and lactation medicine to Direct Doctors.  With a special interest in primary care for newborns and whole families, Dr. Lakin is a great addition to the Direct Doctors' family.   Drs. Hedde & Turshen "are so excited to have a colleague joining us as we expand the services and locations of Direct Doctors direct primary care practices in Rhode Island.  Dr. Lakin is a long-time colleague & friend as well as a phenomenal and caring physician."  Dr. Lakin is currently accepting new patients and will be working out of the East Greenwich office until her new practice location is up and ready in Riverside, RI where she plans to stay long-term. ​

In 2019 we discussed the basics of why patients wait a long time to hear back, get through on the phone lines, or be seen with a primary care doctor.  Unfortunately, this problem seems to have worsened acutely with the COVID epidemic. As an update to that blog, we want to begin by highlighting again that according to Merritt Hawkins, the average wait time for a new patient appointment with a primary care doctor is 29 days, up 50% from 2014. In Rhode Island, the wait continues to be much longer. We’ve heard of patients quoted a six to twelve month wait period before they can see a doctor as a new patient! ​

The Direct Primary Care movement has picked up steam over the last seven years since we started Direct Doctors in RI.  According to DPC Frontier, a site owned by a DPC physician/lawyer who was a founder of the movement, there are now over 1500 clinics doing pure Direct Care across the nation.  There are likely many more than have been officially labeled on the map.  Looking back to 2014, when we began, there were less than 100. ​

Direct Doctors will be celebrating our 7 year anniversary this August! Over that time, we’ve come to really appreciate the direct primary care model that we are using to deliver efficient, evidence based and personal care to our almost 1,000 patients. Like many of the other DPC practices across the country, we’ve noticed many benefits (for both the patient and physician), while also discovering a few barriers. ​

The two most common types of health insurances that we see today (outside of medicare and medicaid) are called PPOs and HMOs.  

The majority of our blogs focus on the healthcare system in general, and how direct primary care can help fill in some of the gaps. Currently, I’d like to highlight some concerns with a more local healthcare issue that has been in the news lately. If you haven’t heard, the long anticipated merger between Lifespan and Care New England has been announced. This deal also involves Brown University who only noted the positive aspects of such a merger in their press release. The Providence Journal conversely, ran a much more balanced assessment article .
 
            Every time large health organizations merge or consolidate, the purported benefits are advertised far and wide: continuity of care will improve, costs will go down, quality of care will go up and the health ecosystem will dramatically change. In this case, we are told that all of Rhode Island will be better off with the two largest healthcare organizations combining powers to produce a health care utopia.... except all the data we have to date shows the exact opposite. 

We have mountains of evidence that whenever this happens, costs go up! When there is a monopoly on services and reduced choice for consumers, patients (or their insurers which eventually trickles down) end up getting charged more for the same services. There is evidence that the same thing happens when physician practices merge or get bought by larger organizations. You want more data? Here’s an article from 2018 showing that though hospital operating costs are reduced 15-30% by this kind of merger, costs still go up!  And how about that “increase in patient care” that is touted. Here’s an article from Harvard just last year that indicates that hospital performance does not improve and patient satisfaction actually goes down. 
 
Interestingly, we do know that one of the only things that does decrease health care costs is access to good primary care. Neither Lifespan nor CNE have ever prioritized primary care, which is consistent among most large health care providers.
 
What is the incentive for large hospitals to have great primary care that keeps patients away from their biggest revenue generators? 
 
Care New England allowed Memorial Hospital to close, displacing the main Family Medicine Residency in the state, which disproportionately affected the large minority population in the Pawtucket/Central Falls area (despite everyone's calls to improve health disparities). Brown Medical School, like many large academic institutions, loves to highlight their students who go into flashy specialties as opposed to holding those who love primary care in similar esteem. So those who are interested in primary care medicine are really exposed only to corporate medicine, PCMH and the types of practices we think need to be changed in the first place. 
 
Rhode Island, as a whole, already has a primary care shortage due to many factors which drives more patients to urgent care and ER facilities subsequently driving up costs for everyone. To combat this, these large organizations are turning more to mid-level providers (PAs and NPs) in their primary care setting. These providers historically order more tests, refer more to specialists, etc… which, you guessed it, also drive up costs. To assist with all of this “continuity,” these large organizations turn to bloated, insanely expensive, electronic medical record and billing software. Then to make up for these costs, primary care doctors are forced to see more patients, leaving little time for good medicine or pension for over prescribing, ordering and referring (as we’ve mentioned in the past)

We do understand that there can certainly be an increase in academic research and improved specialty consultation within these institutions, so it’s not all bad. But in the end, the combination of poor primary care, hospital monopolies and the introduction of more HMO plans into the mix are setting our Rhode Island health care system up for increasing costs, decreasing patient choice without any change in outcomes or patient satisfaction. At Direct Doctors, we will continue to do our part in assisting patients with quality primary care access, lowering their medical costs and improving their overall care!

We often hear from patients interested in Direct Primary Care practices, like Direct Doctors, that they “have regular insurance, so why do I need this too?”  We’ve reviewed the “why” in many prior blogs, but here is the “how” it works. 

Over 95% of our patients have insurance.  They still use it.  If they have specialists to see, colonoscopies to undergo, meds to fill, or labs to get - they still use their insurance.  Direct Doctors can send the order to the lab, refill your prescription at the pharmacy, or refer you to your chosen specialist (we don’t have to stick in the networks like some corporate PCPs) all through your insurance.  This all feels just exactly like you’re used to with a fee for service PCP office.  ​

​We’ve done a few blogs about health care pricing (medications, office/ER visits, etc). Another big health care cost hurdle that patients deal with quite often is the cost of labs or blood work. If you’re a patient with typical insurance, have you ever received a bill from a lab for several hundred dollars for “routine blood work?” You probably assumed insurance would “cover” everything because you pay for an expensive health insurance plan. Or maybe you’re a patient without insurance or a high deductible plan that has to pay for many costs before insurance even kicks in. Have you ever wondered why labs cost so much? Or why the typical primary care practice you were going to didn’t warn you about the costs or ask your financial situation to be sure you could pay for such costs? Most likely, the pricing you received on your bill didn’t look like this:

Every year we release a blog about the open enrollment season and things folks should think about when purchasing health insurance. Most of the information is consistent this year, though I’ve updated things a bit below:

Whether you purchase your insurance through the state, government, employer or directly from the vendors, this can be a daunting process. There are often many choices, with slight differences that are difficult to decipher. Beyond that, because price transparency is such an issue in healthcare, it is often hard to plan or budget for future costs when there is no way to find out how much these services actually cost! Below, I’ve tried to outline a couple tips while going through this process.  ​

Over the past few years, we’ve highlighted the savings of over $3000 in 2 years that the Smith family was able to keep on hand because of being members of our DPC practice at Direct Doctors.

In 2016, we highlighted the following cost savings on medications:

​

In past years we have visited the Smith Family, a typical working family of three looking to reduce their healthcare expenses through a membership with our Direct Primary Care practice, Direct Doctors.  We looked at how they were able to save $1350 during their first year as members of Direct Doctors just by switching to a higher-deductible, lower-premium health insurance and joining the practice for their primary care.  ​
 
We eliminated costs for their family by helping them keep their care in the primary care office setting.  We decreased (in fact, eliminated) their need for specialist visits and handled their urgent issues in our office or via text/email/cell phone when necessary.
 
In their second year as patients, they found additional savings benefits through reduced medication co-pays and laboratory co-pays.  This is no mystery - labs and meds cost more when you use third parties.  ​

​Patients of Direct Primary Care (DPC) practices, like Direct Doctors, have really come to love the ability to reach their doctor through modern technology.  We’re all used to texting and emailing our friends and family - so, why is the traditional medical world so behind on using this form of communication?

There are a few main reasons that your doctor isn’t letting you text them:

This is one of the more common questions we get from patients wondering why they’d pay a monthly fee to join our practice. Many patients “only go to the doctor once a year for a physical,” or “aren’t on any medications.” Others cannot fathom paying for primary care on a monthly basis when they are used to the slow, inefficient traditional primary care practices that are impossible to get in contact with. 

    However, we have many of these patients in our practice. They come to realize that direct primary care practices like Direct Doctors are beneficial for many reasons, even for generally healthy patients. For one thing, many patients realize that they probably use a physician more than they think. Whether it’s an urgent care visit for a sore throat, an ER visit for stitches, or just a simple medical question that required an in person visit at a traditional practice, patients often underestimate the amount they use the medical system, or would use it with a better overall experience. All of these can be handled at our practice, at no charge on top of the monthly fee, in a patient friendly and efficient manner. And that ER visit for a simple laceration repair most likely costs more than a year of membership to our practice. ​

Like many DPC practices across the country, Direct Doctors offers more to our patients than the average fee-for-service (insurance based) primary care practice.  
Some highlights include:

• Cell phone access: that's right...text your doctor, directly!
• Direct urgent contact: to your doctor for input and appointments
• Remote visits: text a photo of your rash, ask for the prescription you know you need for your UTI, and your doctor can handle many clinically allowable issues for you while you stay in the comfort of your home
• Care for the whole family: newborns, kids, geriatrics, well adults, sick visits, end of life care all from the same doctor that knows you all well
• Included services: vaccines, wellness checks, sports physicals, basic gynecologic care, minor skin procedures (wart freezing, skin biopsy, minor wound repair), and even some joint injections!

The process of getting an MRI for a patient used to involve two things - a doctor who wanted an MRI and a patient who needed an MRI.  A doctor is trained for over 11 years (many specialists are trained even longer) to make the right decisions on behalf of patients.  We use that knowledge and training to decide when an MRI makes sense for our particular patient’s situation.

However, in the past decade or two things have changed drastically and continues to become progressively more complex.  Now getting an MRI involves:

• The patient who needs it
• The doctor who wants it ordered
• The insurance company
• The insurance company’s hired third party non-clinical staff who administrates prior authorizations
• The clinical staff at the third party who reviews authorizations

AND

• The billing administrator at the imaging facility who reviews and ensures authorizations are done by the doctor