Picking a doctor is the most crucial step in successfully navigating the health care system. Hopefully, you will never have to get into the belly of the beast, but if you do, you are going to need someone to successfully guide you through the maze. If you have already been pulled into the system, you may need to make some adjustments to get the most benefit and least harm.
The most important step in selecting the right doctor is to have the correct attitude about your potential “health care provider.” I put health care provider in quotes because that is a modern term designed to take doctors down a notch. Almost all physicians (MDs and DOs) consider the term a step down from being a physician. Almost all nurse practitioners, physician assistants, chiropractors, nutritionists, psychologists, and so on consider the term a step up. When you search for a health care provider, I want you to choose a physician. You will understand why shortly.
When it comes to physicians, however, I do not want you to have an image in your head of Marcus Welby or House. We are not looking for an authoritarian figure who is going to take charge and tell you how it is. We do want the expertise and authority that a physician commands, but we don’t want that authority directed at us. Instead, we need that authority directed at the system we may potentially enter.
The best model I have for the role of a physician is that of a sherpa. A sherpa is a native guide and servant whom you take on a mountain-climbing expedition. When you have to engage the health care system or enter the hospital, you should view it in that same way: as an expedition. You will be entering a foreign and potentially dangerous environment. You may consider yourself well prepared. You may even work in the health care field and think you know the ropes. But even the most experienced and savvy climbers will use the services of a sherpa on their journey.
A sherpa is a native to the environment through which you will be traveling. He grew up there and retains all the wisdom that his elders passed down to him. He is considered a member of the territory; everyone you will encounter recognizes that your sherpa is “one of them.” Your sherpa knows the customs and the rituals. He knows how to introduce you to the natives and help you communicate without unwittingly offending anyone. He knows the environment and how to read it. He knows when to push you and when to hold you back. Most important, he is fully acclimated. When you are limping along in a hypoxic haze, he will be in top form, able to look out for you when you are too tired to be vigilant. Finally, he knows when the expedition should be scrubbed, or at least when you might need a return to base camp.
Despite his superior knowledge, conditioning, and familiarity with the environment, the sherpa knows he is your servant. His authority is always delivered in a subservient fashion, because he knows you are the one paying him. He lets you set the goals and agenda and tries to accomplish them within the constraints of reality. When your goals conflict with the environment, he will tactfully and firmly inform you of the issues. He will present the facts and leave the decisions up to you (or at least make you feel like you are in charge). If your desires pose a danger to yourself or to your sherpa, he will reserve the right to sever the relationship, but will do almost anything to persuade you before he does so. If he is not comfortable with your demands, he will do his best to find a replacement willing to accommodate your wishes.
As you move through your expedition, your sherpa expects to do the heavy lifting and to take the lead facing all the headwinds. However, when you reach the summit, he expects to fade in the background as you stake your flag and pose for pictures. Once the photos have been taken, he will help you pack up and come back down the mountain in the quickest and safest manner possible. The sherpa knows how to get you out of his world and back into yours.
Finding a physician to be your medical sherpa will be difficult. As we discussed in the first section of the book, the political and financial forces in medicine have conspired to make it almost impossible for a doctor to operate this way. First and foremost, you want a doctor who still admits his1 own patients to the hospital. If you ever have to be admitted to the hospital, you want your hired sherpa directing your journey. Your doctor will have affiliated with what he believes is the top hospital. He knows the system. He knows what floors are best and he has a relationship with the nurses, techs, and ancillary personnel. He knows when the “A-team” is on, when the “B-team” is on, and how to get the most out of both of them.
In addition to selecting the best hospital and guiding your way through it, your doctor will also have developed a referral network with all the different specialists you may need. Your doctor should have a good reputation and a working relationship with the emergency medicine doctors in the ER. Many times, the only entry to the hospital will be through the ER so that stabilizing treatment and expedited testing can be done. If your doctor has the ability to notify the ER of your condition and what workup may be needed, this will accelerate your care and prevent unnecessary testing. Your doctor should also have a relationship with other specialists such as cardiologists, surgeons, and orthopedists. The specialists should be responsive to your doctor because of the prior referrals that represent the “bread and butter” of his practice. If you suddenly rupture your Achilles going for a jump shot on a Saturday morning, it will be great if your doctor can notify the ER and the on-call orthopedist of his choice that you are on your way in.
You can see that having a doctor is something that you must research and establish when you don’t need care. This is because a personal doctor is a lot like a tourniquet or a fire extinguisher: you hopefully will never need one, but when you do you, will need it badly and right away. Unfortunately, a doctor of this type is going to be very hard to locate. Combine this with the fact that you will be seeking a doctor with these characteristics who also will be on board with your ancestrally inspired health plan.
In essence, you are looking for a doctor who embraces three characteristics, each of which is rare. To find all three in one doctor is indeed challenging. The three characteristics we are looking for are: 1) a free market orientation, which does not imply particular political beliefs but instead relates to the doctor’s views on the provider/client relationship; 2) knowledge and support of a primal, wellness-oriented approach to health care; and 3) someone who still admits his patients to the hospital and has a strong presence within that institution.
In general, the third of our requirements will be the hardest to find. As we discussed in the first part of the book, political forces and price controls have driven doctors from the inpatient side of medicine into the outpatient arena. Many doctors have also become fed up with the “disease management” aspect of medicine, overseeing patients who are unwilling to participate in their own healing. It is therefore quite easy to find primary care doctors who have moved into the outpatient arena and who focus on “wellness.” Many of these practices focus on bariatrics (weight loss), hormonal management, and nutraceuticals. However, most of these practices exist for the express purpose of escaping inpatient medicine and thus do not participate in the care of inpatients.
While I obviously support the concept of wellness, and feel these practices offer valid services, I also believe that wellness does not require a physician to achieve. Wellness is your default state that is encoded in your DNA and can be acquired by following the principles of the primal lifestyle and diet. You do not need a doctor to be well. You definitely need a doctor if you become significantly ill or injured. As much as this will rub wellness practitioners the wrong way, medicine exists to treat disease and injury. You simply must choose a doctor who can take care of you when sickness or injury occurs.
Your doctor must also be capable of caring for illness or injury in the office. You should ask your candidate doctor if he is able to sew simple lacerations, or splint non-displaced fractures. Does he have basic lab and x-ray capabilities, or a relationship with a hospital or outpatient lab and medical imaging center? Does the practice hold daily slots open for acute illnesses or injury? You don’t want to be told to go to the ER for something that should be handled in an office. If that happens you will incur much more expense, as well as a prolonged wait time because you will be triaged low in the queue.
Finding a free market oriented doctor is challenging and depends on the Golden Rule, to wit: he who holds the gold, makes the rules. The proper relationship between a doctor and patient should be a direct exchange of money for services rendered paid at the point of contact. This makes it crystal clear who the doctor is working for and whose wishes need to be followed.
When the doctor is being paid by a third party to take care of you (as well as thousands of others), the wishes and needs of that third party take priority over the needs of you, the patient. Overall patient demographics and administrative overhead play a major role in determining the type and extent of treatment that you will be offered. In a third-party payment system, the medico-legal risks are collectivized. In order to decrease the overall risk of a malpractice suit, the third-party payer may enforce more extensive workups than you or your doctor might otherwise want. As we will discuss later, more extensive workups have their own set of dangers. When testing is done just for the appearance of thoroughness in order to decrease malpractice risk, you face a greater chance of false positives. These false positives can trigger further testing and treatment that can actually produce harm even though the original intent of the testing was the appearance of safety. Extra radiation and invasive procedures (with risk of injury or infection) are some of the potential harms, but we must also consider the anxiety and worry that go along with unnecessary testing.
The solution to the problems of third-party interference is to seek out a doctor who accepts direct cash payment from his patients and determines the price structure for his practice (as opposed to having a fee schedule that is determined by insurance companies and government payers). This arrangement allows the doctor to bill you directly for services and then provide you with the paperwork to file with your insurance. The physician can then receive payment directly from you without having to go through any intermediary, in turn cutting all of the administrative overhead for the doctor. He doesn’t have to file paperwork; he doesn’t have to code his medical record and diagnosis in order to apply for reimbursement. There is no prior approval process where he has to figure out if your diagnosis and treatment will even be covered. Also, the payment is received in real time, opposed to the substantial delays with insurance reimbursements. Because of these delays, most doctors have to rely on a billing service to keep track of who has and has not paid and to make sure that payments do not fall through the cracks. In general, the doctor being paid through third party insurance employs a small army of office staff and billing and coding technicians just to try to get reimbursed. These headaches will only increase as the Affordable Care Act’s provisions sink in.
The doctor who deals directly with patients can rid himself of all of this overhead expense, and therefore can offer services at a greatly reduced price. Simple office visits can drop as low as $25 to $40 (as of this writing). The requirements for documentation are not as onerous and the treatment you are given (or not given!) can be that which you and your doctor discuss. If you don’t want to be on a statin, your doctor can abide by your wishes without risk of third party payment denials for failing to follow “best practices.”
Note that you can have traditional employer-based insurance and still participate in this sort of medical practice; you will just have to file for reimbursement through your insurance company. The practice will generally provide you the paperwork and guidance for you to get reimbursed.
More ideally, you can combine this kind of care plan with a “catastrophic” insurance plan. This type of plan generally involves a high deductible ($5,000 is typical) and pays 100 percent of your medical bills and hospitalization after that deductible is met. This makes health care insurance actual insurance again. If you think about your car insurance or your homeowner’s insurance, you will see that you are not reimbursed for routine or preventive maintenance such as oil changes or repainting. Instead, insurance is for some catastrophic and unforeseen circumstance that would be financially devastating if you had not paid into a risk pool in exchange for coverage. When you revert to true health insurance, your premiums drop significantly, and when it does kick in, your coverage is complete. As a result, there is less fighting about what is covered. When there is lower risk of premiums being consumed, the payment restrictions are less.2
Concierge doctors provide care in a manner similar to cash-only plans. The major difference is that they charge an upfront fee instead of charging by the visit. The fee can range anywhere from $500 to $5,000 annually. In exchange for this yearly fee, you get unlimited and unfettered access to your doctor. All visits during the agreed upon contract time (typically a year) are covered under the retainer fee. You will have 24/7 access to your doctor by a cell phone that he carries at all times. The money spent on the retainer may or may not apply towards the deductible of your insurance, and will depend on your policy. The chances are greater for the fee to be deductible if you make these arrangements at the time you are purchasing your insurance policy.
The advantage of a concierge practice is that the higher up-front fee allows the physician to have a much smaller number of patients in his or her practice. Instead of the 3,000 to 5,000 patients that constitute a medical practice, the concierge physician may have only 500 to 2,000 patients. This allows the concierge physician the ability to be available to his patients at all times. Even if you never use the physician during the year, the peace of mind in knowing that your doctor is available to you immediately any time of the day or night may be worth the price of the retainer. Also, many concierge doctors are affiliated with each other and can offer promises of cross-coverage, allowing you similar access to medical care even when you are away from home.
The difference between a concierge practice and a conventional insurance-based practice is about as dramatic as you can get. With the Affordable Care Act going into effect, the pool of patients with insurance coverage will expand greatly. As a result, traditional practices will be seeing much larger numbers of patients at a declining reimbursement rate, which will only make this discrepancy even more extreme.
Although there is a potential conflict in concierge practices— because the patients may adopt a “buffet mentality” while the providers may try to avoid work that is unreimbursed—in practice this does not seem to be a problem. I believe this is because this sort of transaction tends to occur higher in the economic food chain with people who truly understand the value of what they are paying for. This engenders a mutual respect between the physician and the patient, which seems to easily overcome the potential problems we discussed.
As we have discussed previously in this book, Medicare is the most onerous of the third-party payers and has served as the template for everything bad in commercial insurance. Many, having reached age 65, feel that they have paid into the system all these years and now need to get their money’s worth—the “buffet mentality.” Also, seniors must consider that the money they have paid in is long gone; the government didn’t invest those payroll “contributions” over the years in the S&P500. Any Medicare “benefits” extracted from the system are being paid for by involuntary withdrawals from current workers’ paychecks, or (if financed via deficits) by the future tax payments of your grandchildren.
Therefore, I recommend operating outside the system as much as you can. To operate on a cash basis with your doctor, you must either rely on your doctor for services not paid by Medicare (routine preventive care or cosmetic procedures), or you must sign a private contract agreeing to give up Medicare payment for services rendered by your doctor and instead pay the fee set privately by your doctor. This is at best a general discussion on how to get care outside of Medicare and you may want to contact HCFA (Health Care Financing Administration) directly for further detail. Many physicians who provide cash services have opted out of Medicare entirely, and because of CMS regulations and how hospitals are funded, many are disallowed from inpatient care. The solution for many independent physicians who have opted out of Medicare is to simply not bill for inpatient services provided to the patients in their care. Others may rely on a hospitalist service that they stay in close communication with, should you be hospitalized. I prefer the former arrangement, but if the hospitalist route is necessary it should not be a deal breaker, especially because most traditional insurance-based practices rely on hospitalists as well.
You need to acknowledge that Medicaid is not insurance; it is welfare. As such, you are not participating in a market exchange and thus have no real right to input regarding your care. You are stuck taking what you are given. You are utterly at the mercy of the government and health care bureaucracy, and that’s why—for both your financial and medical wellbeing—you need to exit this situation as quickly as possible.
Having said that, the most important thing you can do is take any job or jobs that become available and begin to purchase your health care through a cash-only approach. In fact, many Medicaid beneficiaries cannot get care because so few physicians are accepting Medicaid patients. (The reimbursement is so low that a practice cannot see Medicaid patients and expect to keep their doors open.) Many patients that attend charity clinics are actually on Medicaid but end up there because of the lack of Medicaid-accepting doctors. Likewise, many cash-only practices have a significant number of Medicaid patients because the care is so affordable. The only good advice I can give about Medicaid is to use it for what it was intended to be: a temporary situation to give you a “hand up,” so that you can become productive and self-sustaining again.
When I say what kind of doctor, I mean what specialty. I must preface my recommendations by informing you that what follows is not based on the scientific literature, but instead is my opinion based on a quarter century in the trenches interacting with generalists and specialists from all different fields.
When selecting a personal physician, you want someone whose training has given some direct experience in all the different specialty fields. This makes the physician able to deal with problems from almost any specialty. If you have a mild to moderate problem, your doctor can usually handle things as well as a specialist. If the problem is severe— such as a perforated ulcer—then your general physician won’t be doing your surgery, but he or she will have done several months of surgery rotation in residency and know what to expect, whom to call, and how to expedite your transition to specialist care. In short, I am talking about someone trained in family medicine.
Family medicine or family practice-trained doctors rotate through all the specialties of medicine, but with a special emphasis on office practice. They are trained to be “team leaders” and to coordinate the care of specialists. Not all family practitioners take on the role of team leader: many will “punt” you to a specialist and defer entirely to the specialist’s opinion. However, their training at least grants them direct experience in other specialties, the ability to coordinate care between multiple specialists, and the competence to accept or reject their consultants’ opinions based on a patient’s overall needs. Having been in this position in the past, family physicians will have developed a network of specialist consultants who they feel are the best among those available to them. Further, since these specialists depend on family physicians for referrals, they are very responsive to their requests for consultation. This all serves to benefit you, the patient.
Another advantage of family medicine specialists is that their practice is not constrained by age, gender, or body system. This may make them a “jack of all trades/master of none,” but it also gives them a broad and integrative overview of medicine. This means that one doctor can oversee your entire family from infancy to adulthood and old age. Some still provide excellent obstetrics services as well. Doctors using a cash practice are very rare, so if you find one that can provide care for your entire family you can save yourself from a potentially time-consuming search.
If you are an older adult, an internal medicine specialist may be a good choice as well. Their training is not as broad as a family medicine specialist, but their experience with the diagnosis and treatment of medical conditions is very extensive. Since most adult illnesses are medical in nature, internists can be a very strong choice. General internists tend to function well as referring doctors for surgical or non-medical issues just based on necessity and experience in community practice.
Pediatricians are excellent choices for your children, but once your kids reach their mid to late teens, you may need to transition to an adult physician (family or internal medicine).
I generally discourage women from using their OB/GYN doctors for their primary care. I do not think their breadth of training is sufficient for general medical care. It works fairly well until you get sick outside the realm of gynecologic issues. (I strongly think OB/GYN doctors should be used for pregnancy care and gynecologic conditions.)
Once again this is a personal opinion, but I definitely recommend relying on an obstetrician or family physician for prenatal care and delivery of your baby. Nurse midwives and doulas are fine as long as their care is provided in (or affiliated with) a hospital and with some form of physician backup.
I realize that many people—including those in the primal community—hold a negative view of hospital-based deliveries. Even so, I advise against home or out-of-hospital deliveries even when performed by physicians (but especially when practiced by non-physicians). When a baby comes out blue, breach, or in respiratory failure, 911 gets called and the crisis is dumped in my lap in the ER.
Your doctor may employ mid-level providers such as physician assistants or nurse practitioners. I think this is fine. These people are well trained and can offer excellent care, often even better than their physician counterparts.
Their training, however, is directed toward the less serious conditions. As such, I think they are great for your routine office care and even rounding on you in the hospital. Yet I recommend that each of your visits to the office at least involve a brief encounter with the supervising doctor and some indication that he or she is overseeing your care. If you become more seriously ill, you will need the physician’s direct care, and that care will benefit from having prior familiarity with you as a patient and as a person.
There are alternative providers of health care such as chiropractors, naturopaths, homeopaths, nutritionists, and numerous other therapists. They certainly may have a place in your health care and wellness plan. However, they should not serve as a substitute for a physician who will care for you when you are sick. Despite the move towards “wellness,” medicine is still about caring for the sick or injured. If you face a serious health crisis (especially if you require hospitalization), you will need a doctor. You will be best served if you have established a proper relationship with a great doctor who is on your payroll, and you establish the relationship long before you actually need it. Do everything you can to be well, but be prepared for when things don’t go as planned.
Finally, an acid test to apply when selecting a physician is his willingness to avoid prescribing medications, or to help you wean yourself off prescription medications if you are already taking them. This is such an important issue that we devote the next chapter to it.
