Concierge Medicine

Among the many problems surfacing from the rollout of Obama Care are controlling the cost of services provided by a limited number of carriers or Providers of care. Exchanges, which were designed to be competitive have fewer carriers willing to participate, and sometimes only willing to participate in urban settings where they can contract cheaply.

Meanwhile the Providers, who were approached by carriers they were familiar with found themselves asked to take lesser pay for services, since the ACA shaved the margins of the carriers, added taxes to support the Act, and wrote into law greater risks, Benefits, and caps to Administrative costs.  This has caused the Providers to make one of three business decisions:  retire, group to reduce their overhead, or limit their practice and set an acceptable annual income.

One manner to do the latter was to incorporate into Accountable Care Organizations, which I have written about in the past, but which are essentially the grouping of hospitals, General and Specialist Physicians and even ancillary personnel and services, accepting set fees and performance measures, which they distribute among themselves.

A second choice and one that grew more than 25% in 2011 and probably more in 2012, is what is termed Concierge or Direct Patient Care practice.  An easy way to think about this is that a Physician decides on a workable number of patients he can provide personal care to, and pares his practice to that number. For the most part these are Internal Medicine or Family Practice doctors, but there are commercial groups, such a One Medical in NYC, the Bay Area, Washington DC, and even in LA and Orange Counties, and MDVIP, primarily on both coasts.

Fees vary widely, some as low as $195/year; others perhaps $5,000 annually.  This is explained for the most part by whether the doctor continues to bill for services (or expects the patient to submit to a carrier) or whether most services are provided with no copayment.

The attraction to the patient is access, personal contact, and emphasis on wellness.  Most DPC or Concierge practices guarantee appointments within 24 hours of request.  Most also work with patients through email or texting. Follow-up after appointments is a definite plus. Many MSAs through employers will allow use of pre-tax dollars for services provided through DPCs or Concierge.

For the physician advantages include: a feeling of better contact with the patient, fewer forms and less third-party regulation, a more predictable income and in some cases, a path towards retirement.  This latter is an attraction that is influencing dentists and even Pediatricians into the concept.

Whether this alternative is a good choice for you is a matter of personal choice.  The controversy on the issue is that it would seem to establish a two-tiered healthcare system, benefitting the wealthy. The fact of life is that as the weaknesses of the Affordable Care Act become more evident, the choice to physicians may become moot.

In my next post I will convey why seeing the play Matilda made me think of my wife Mary in a new light.  I hope you'll join me.

Finding Foods

Recently I was at one of the Markets where I buy fresh produce (and a blend of great beef).  My aim was to buy some oranges since I have fresh orange juice about three times a week, and the oranges there are much cheaper than most markets.  I noticed a woman choosing her oranges.  She would pick one up, look at it, and put it back to choose another.  I was tempted to ask her what she looks for because most oranges look alike to me.  But her system mimicked that of a professional tennis player in choosing which ball to use in serving.  I don't understand that process either, and I have played tennis for years. So, my embarrassment stopped me short.

I do have some ways that I choose my produce for other things.  Mostly this has come from my weekly visits to the nearby Certified Farmers Market.  For instance I pick tomatoes by smell.  If they don't smell like a tomato, I leave them for someone else.  Smell also is a deciding factor with cantaloupe, but I also use weight and depression of the stem on the end.

Mary asked me how I choose grapefruit.  That would be by weight.  The heavier, the  juicier.  Strawberries, peaches and apples?  If you buy them at the market, you take a taste.  BTW, you should buy your strawberries from a farm that is either certified organic or follows organic principles regarding pesticides.  When the seeds are on the outside and there is no skin to peel, rinsing is more a ritual than an effective cleansing procedure.

Not all vendors at the market are certified organic.  The certification process is very expensive and takes a long time.  Many of the farmers have relatively small operations and can't afford high overhead.  I don't think my favorite farmer, Jimmy the Avocado and citrus man is certified, but he knows the oil content of every avocado he sells.  He is the one who told me the genesis of the Haas Avocado, a story well worth reading.

I asked Jimmy if I was correct in thinking weight was the best determiner for citrus and he corrected my opinion.  "Seasonality is what's important.", he said.  "That and carbon footprint." "Oh, and finally, personal taste."

In California, especially in Irvine where  live, we are fortunate to have the hybridized Valencia orange, which comes to market about now and is available through most of the summer.  It's cousin, the Blood Orange, also shares a similar seasonality.  We are also fortunate to have a 12-month growing season of the more common, naval orange to meet my weekly demands through the entire year.

Jimmy says that different cultures want variety of sweetness in their orange, due no doubt to what grew in their country of origin.  Our Mexican and other neighbors to the south seem to like their citrus sweet, while his customers from the Middle East prefer a more bitter taste.

My mother told me that when I was a baby in Iowa I had an allergy to oranges, but after a few years of deprivation, I have been on a quest to catch up ever since.

 

Choosing vegetables is a developing art for me.  A friend who is a chef and a great foodie, used to tell our Days of Taste students to look for indications that insects have tried the vegetable or apple, because if they liked it, so would you.  Again, the best indicator is what is in season.  For instance, Mary wanted to try a recipe for Root Vegetables Gratin and, while I could find golden beets, carrots and turnips, the parsnips aren't in the market yet.  I suppose I should be grateful that we have a year-round growing season here in Sothern California, especially when I see the winter my mid-western relatives are experiencing.  Not that we don't have our own problems.  Jimmy told me that he literally took of all branches of 1/3rd of his avocado trees because the water was driving his costs beyond what the market would bear.  He says they will grow to fruit-bearing size in about three years at which time he can repeat the process with other trees if we haven't solved our water problem.

I recently visited our state capitol twice for legislative information on California's Exchange, Covered California.  I wouldn't presume to capture the effects of the ACA, but I think in my next post I'll share what I know about Concierge Medicine.  You might find that interesting.

Everly

Phil Everly died recently at the age of 75 and I was surprised at the amount of press his death generated.  Searching for an explanation, I re-listened to Foreverly an album that Norah Jones and Billy Joe Armstrong released late last year.  Viola!  The thing that made them so memorable was not so much the songs as the harmony.

There were times when the harmony on the songs their father had sung to them as they were growing up when neither Billy Joe nor Norah was singing the lead melody line.  Turns out there is a name for that.  It is called "diatonic-third harmony", and it became an influencing model for some of the greatest names in Rock and Roll.

I bought two other albums that have relevance, both by Linda Ronstadt: Trio and Trio 2.  I read her biography Simple Dreams a few months ago.  Although her musical career embraced many different forms of music, and more than one language, she had a special affection for harmony.  These two albums feature harmony  with her favorite musicians: Emmy Lou Harris and Dolly Parton.  She also did an album featuring the Everly Brothers.

I can appreciate her love of harmony.  While in college I joined a quartet that harmonized in the classical manner of Barbershop. It seemed a natural as I grew up in Mason City, Iowa, which was the home of Meredith Willson, who brought Barbershop to Broadway with Lida Rose from Music Man.  I continued membership in the SPBSQSA and sang with several different groups over the next several years, always enjoying the fellowship and the talent of others in the demanding art form.

Now, with few exceptions in musicals I have been in, I confine my singing to weekly hymns, and my harmony to Christmas songs, but I enjoy listening and will return to some of the songs done by those confessing influence from the Everly Brothers: a fairly impressive list that includes:

·         The Beatles, greatly influenced by the Brother's success in Great Britain

·         Buddy Holly, who gave up his Letter Jackets for the Ivy League look of the Everlys

·         The Beach Boys, who literally rode the wave of story-telling Rock and Roll

·         The BeeGees, and

·         Simon and Garfunkel.  Paul Simon called their voices the clearest in the history of Rock and Roll

For some reason it seems to me that harmony has fallen out of fashion.  I get a weekly dose by listening to Prairie Home Companion, where Garrison Keillor always manages to use the skills he claims to have learned in his Lutheran youth., and occasionally find an established group, who issue a new album, such as Uptown Vocal Jazz Quartet who made a hot a cappella jazz album in 2012 called Hustlin' for a Gig that I especially liked.

Come to think of it though, a cappella singing is making a comeback and not only from the Benedictine Nuns.  And the harmony of that singing is as beautiful as any that the Everly Brothers did.  Maybe I'll just change my diet from Rock and Roll to Gregorian Chant.

In my next post I will share some of the tips I've found from my weekly visits to the Farmers Market.  If you want o know how I pick my fruit and vegetables, stop on by.