Heal Thy Practice 2011: Improving Outcomes, Improving Incomes

In an ideal world, physicians would be rewarded for helping people restore and maintain true health. They would have time to focus fully on the needs of each patient, and there would be support for comprehensive, lifestyle-based care that fosters real healing, not just symptom control and medication management.

If that seems like wishful thinking in a world of 10-minute visits, reimbursement cuts, utilization review, and compliance monitoring, rest assured there are physicians practicing exactly that way….and successfully!

They’re ordinary doctors, just like you, who’ve built practices that reconsacrate the patient-practitioner relationship, and truly improve health outcomes while simultaneously improving practice income.

To paraphrase Dickens, these are the best of times, these are the worst of times in primary care. In most clinics, there are more obstacles than ever to healthy doctor-patient relationships, and many forces threaten the very viability of solo and small-group practice. At the same time, there is tremendous innovation and creativity in the field, as physicians work with patients, employers, and even insurers to develop new, truly health-centric models of care.

The need for lifestyle-based medicine is stronger than ever, as is the public’s valuation of it—evidenced by the continued growth of prevention-focused direct-pay practice models, despite the economic doldrums.

Holistic Primary Care’s Third Annual Heal Thy Practice: Transforming Primary Care conference in Long Beach, CA, Nov. 4-6, gives you an opportunity to learn about transformative practice models and therapeutic techniques from clinicians who’ve successfully put them into real-world practice. You’ll be able to explore and overcome the obstacles stopping you from creating the kind of practice you really want.

Masley_HTP2010Chaired by Dr. Steven Masley, Founder/Director of the Masley Optimal Health Center, St. Petersburg, FL, one of the nation’s most successful functional medicine clinics, Heal Thy Practice offers two and half days of lively didactic sessions and interactive workshops in the spirited company of like-minded clinical colleagues from across the country.

Here are some clinical pearls and practice development tips from Heal Thy Practice faculty members. It’s just a taste of what’s on offer at this innovative conference.

Stop Fighting, Start Dreaming

“People hear my story and say things like, “Keep up the good fight!” But in reality, it hasn’t been a fight. Creating my clinic is the easiest thing I’ve ever done,” says Dr. Pamela Wible, a Eugene, OR, family physician and pioneer in community-based clinic design.

In 2005, after working for years in a variety of frustrating settings, Dr. Wible began envisioning what her “ideal” clinic might be like. She shared that vision in town-hall meetings, gathering input from neighbors about what they wanted and needed from a community clinic

The result? A thriving, patient-friendly center offering a range of holistic options at Wible2affordable prices. She keeps her overhead low, accessibility high, and her attention on the main thing: helping people get well. Most importantly, she’s eliminated the frustration factor (for a detailed account of Dr. Wible’s journey, read “Want an Ideal Clinic? Collaborate with Your Community!”).

“It begins with “What if…?” When you allow yourself to dream unrestrained, and you inspire others to do the same, new possibilities emerge.” For that to happen, you need to let go of fear, anger, cynicism, and disappointment. Here’s a three-step exercise that can help you make “space” for new possibilities:

1) Imagine what may be holding you back in your life.
2) Feel your authentic feelings about these things one last time and write it all down.
3) Crumple up your paper and throw it in the trash.

Do this together with your staff or with members of your community, and you’ll be surprised what fresh, creative ideas start to percolate.

This community-based approach to health care reform will be the subject of a documentary film, tentatively titled “Doctoring for Democracy,” which Dr. Wible is co-producing with filmmaker Normandi Zaurice Parker.

Overcoming the “Blue Light Special” Mindset

Many clinicians, when moving from insurance-based practice to cash-pay, start out by offering a special “discount fee” for patients who pay direct. This is understandable, and reflects a desire to “reward” cash-pay patients.

CherewatenkoUltimately, though, it’s misdirected, because it’s based on devaluing rather than re-valuing your services, says Dr. Vern Cherewatenko, founder of SimpleCare, one of the nation’s first direct-pay practice networks, now representing over 1,500 physicians nationwide.

A Seattle-area family physician, Dr. Cherewatenko has vast experience in making direct pay a clinically effective, cost-saving reality for doctors and patients alike.

Insurance plans have entrained practitioners to devalue themselves. “After you factor in the cost of getting paid in an insurance model, you’re getting much less from the plans than from your cash-pay patients. The plans are getting the discount, not the cash-pay patients!”

What you should offer your direct-pay patients is a fair, honest price for your time, expertise and total commitment to their best interests, not their insurer’s! If you minimize your overhead and manage your practice well, you can do this at a fee even people of modest means can afford.

“Don’t demean your value by perpetuating the discount mindset. You’re a highly skilled, well-trained, dedicated professional, not a K-Mart ‘Blue Light Special,’”

At Heal Thy Practice, Dr. Cherewatenko will explore the practical nuts & bolts of a successful direct-pay primary care practice & share tips for making the conversion whether you want to do it all at once, or more gradually.

How to Identify Patients Open to Change

What if there was one simple question that could help you identify which patients were most proactive about health and most willing to embrace a new practice model?  

There is. It’s this: “Do you have a Health Savings Account (HSA) or Flexible Spending Account (FSA)?”

Most practitioners never even think to ask, which is unfortunate, because it’s a wickhamvaluable bit of information, especially if you’re thinking about moving to a direct pay model, or integrating a new revenue stream into your practice, says Steve Wickham, President of SG Wickham & Associates, a practice development consulting company.

“People who have HSAs or FSAs are basically telling you that they’re looking for something different, something beyond “standard care” in insurance based medicine. They’re more likely to be proactive about their health,” Mr. Wickham explained. “It should be a routine question on your intake forms. You already ask about what insurance they have, why not ask about these additional accounts?”

Most FSAs and HSAs do not directly cover vitamins, herbs, or other “alternative” therapies. But it is possible to bundle these things into comprehensive, condition-specific programs (eg: weight management, glucose control, CVD risk reduction, etc), which are eligible expenses in most FSA/HSAs.

Demystifying Vitamin D

A recent Tufts University study showed that daily supplementation with cholecalciferol (Vitamin D3) substantially increased pancreatic beta cell function and improved glucose control in overweight pre-diabetic people.

The case for recommending vitamin D grows stronger with each new study, but there is still controversy about dosing, says Dr Steven Masley, MD, director of Masley Optimal Health Center, St. Petersburg, FL. “Dosing can be tricky. On the one hand, it makes sense to supplement to get blood levels up in the range of 40 ng/ml. But you don’t want to overdo it and increase the risk of calcification.”

Learn to tailor your supplementation by estimating a patient’s cumulative total vitamin D load, bearing in mind that people get vitamin D from sun exposure as well as various foods.

Here’s Dr. Masley’s handy guide for making estimates:

Multi-vitamins: Most products contain between 200-500 IU.
Cold Water Fish: A 3.5 oz serving of oil-rich cold-water fish (tuna, salmon, mackerel etc) contains 200-350 IU
Cod Liver Oil: 1 teaspoon gives roughly 100 IU
Fortified milk or soy milk:  One serving typically contains 100-150 IU
Egg Yolk:  One egg yolk contains approximately 25 IU
Sunshine: Mid-morning exposure for 20-30 min, wearing short shirt & pants, thrice weekly gives roughly 200 IU/d, though this varies considerably with age and location. The skin of a 70-year-old makes 75% less vitamin D than the skin of a 20-year-old, given the same amount of sun exposure.

Using himself as an example, Dr. Masley said, “I get 600 IU from a multivitamin, plus about 200 from eating fish twice per week, plus 100 from other calcium & vitamin D-containing foods, and about 200 per day from exposure to the Florida sun. This means, I’m getting about 1,100 IU per day, and my 25-OH vitamin D blood level is 38 ng/ml, with this cumulative intake level.”

Testing for vitamin D makes sense when you suspect rickets, osteoporosis, multiple sclerosis, autoimmune disorders, or unexplained muscle or bone pain. “If you do test, make sure you test for the 25-OH metabolite, not the 1,25-OH. The 25-OH level should be well over 35 ng/ml. Levels under 32 are definitely low.”

Vitamin D is among a host of key nutrients Dr. Masley will cover at Heal Thy Practice during his popular “Cutting Edge Nutrition for Primary Care” talks. He will also share his insights on how to implement nutrition-based care in a financially viable way.

How to Reduce Prostate Cancer Risk

cheethamProstate surgery is a lifesaver when truly needed. But many men with low grade, low volume prostate cancer are sent for unnecessary surgery when they would benefit more from holistic lifestyle interventions, says Dr. Philippa Cheetham, a urologic surgeon at Columbia University Medical Center, and co-founder of the Society of Holistic Urology.

Here are four key tips for keeping men with low-grade neoplasia out of the surgical suite:

Reduce the Red: “Red meat is bad news,” Dr. Cheetham says. Broiled or barbecued red meats seethe with carcinogens. There are over 20 studies showing high red meat consumption increases prostate cancer. That’s definitely a bummer for the steak & potatoes crowd who make up a good percentage of prostate cancer patients, but it’s a dietary change that can be life-saving.

Pile on the Purple: “Increase your intake of anything purple,” she said. That includes grapes, berries, black currants, pomegranates, and any other blue-purple fruits & vegetables. They’re rich in anti-inflammatory, anti-oxidant and anti-neoplastic compounds. This list includes red wine, too. A glass or two daily gives plenty of reseveratrol. It’ll also help the guys cope with giving up their prime rib!

Crunch the Crucifers: Broccoli, kale, spinach, cauliflower, Brussels sprouts, arugula..…all the cruciferous vegetables are prostate-friendly, containing beneficial sulforaphanes which have definite anticancer effects. Crucifers also provide lots of other nutrients and fiber.

D on the Double: If you have prostate cancer, there’s a 75% chance you’re vitamin D deficient, says Dr. Cheetham. A healthy D3 level is in the 30-80 range. Most men with prostate cancer are down below 20. It’s a particular issue for black men. She advises 5,000 IU daily for men with early stage disease. “It helps boost immune system function.”

Many other things can help: green tea, turmeric, Active Hexose Correlated Compound (AHCC—a proprietary extract of several species of medicinal mushrooms). “If we can reduce inflammation, we can change the course of cancer,” she said. “We’ve got good data from biopsy studies that we can reverse pre-cancerous changes”  

If men start making these changes before they have pre-cancerous changes, they can reduce lifetime risk from about 1 in 6 to roughly 1 in 100. “That’s huge!”

Check Dr. Cheetham on the “Katz’s Corner” radio program on WABC radio:

Understanding the Genetics of Weight Loss

Some people seem to gain weight no matter how carefully they eat. Others pile their plates and never seem to gain a pound. Likewise, some people tone up fairly easily when they cut calories and up their exercise. Others try every imaginable diet and exercise program, yet can’t make a dent in their BMI.

There are reasons for all of this—genetic reasons, says JJ Virgin, one of the nation’s jj-virgin_2most highly sought personal trainers and weight loss experts.

To be sure, the ubiquity of cheap, high-calorie junk food is a major driver of obesity, but individual genetics plays a far bigger role than many people realize. Nutrigenomic researchers have now identified hundreds of genes influencing everything from food preferences to metabolic responsiveness to exercise.

For example, a gene called TAS2R38, regulates perception of bitter thiourea compounds on the tongue. Variations of this gene result in 3 distinct taster groups: super-tasters, medium tasters and non-tasters. Differences in taster status are linked to differences in body weight, alcoholism, cravings for sugar and fat, and fruit/vegetable preferences. In one study, non-tasters had higher mean BMIs than medium or supertasters.

“The notion that genes affect our apparently voluntary behavior is, understandably, uncomfortable for many people. But the fact is, genetic factors are estimated to account for 40–70% of the variance in human adiposity,” says Ms. Virgin.  The more you understand about the genetics of weight gain, the better able you’ll be to design individualized diet and exercise programs that will actually work!

The tests exist. It’s a matter of knowing how to apply them. At Heal Thy Practice, Ms. Virgin will explore the cutting edge of nutrigenomics in clinical practice, and explain how to implement science-based weight loss programs that provide a real foundation for wellness-based practice.

Become the Voice of Health in Your Community

“People are looking for a trusted voice. If you can be that voice, and you give people accurate, salient information that helps them make healthier choices, you’ll have a busy practice forever!” says James Maskell, co-founder of Revive Communication, a Brooklyn-based practice development firm.

Mr. Maskell and his wife/partner, Rachel, believe the best practice marketing strategies emerge when physicians become trusted advisors and information sources for their communities. “As patients become more educated, they will naturally seek out your services. The ‘marketing’ happens almost by itself.”

JamesMaskellMany doctors these days are trying to generate new revenue with cash-pay procedures or services. Their marketing plans—if they have any—consist in advertising these services, and hoping they’re edging out other practices in the area. That’s not necessarily the best approach, says Maskell.

“Share info about your patients’ key health concerns, not the procedures you’re trying to ‘sell.’” For example, if you’re introducing chelation in your practice, start by sharing good information with patients about the role of environmental toxins in various chronic diseases, and the problems that can happen when the body’s natural detoxification systems become impaired or overloaded. Patients who have personal concerns about these issues will naturally want to know what treatment options are available to them.

The key, says Maskell, is to make sure the info you share is truthful, relevant to patients’ day-to-day lives, actionable and empowering. If you produce an email newsletter for your patients—and you should—make sure that 80% of the content is truly educational and non-promotional. The other 20% should be things like “patient appreciation offers,” notification about educational events at your clinic, or other events you think would be helpful to your patients.”

At Heal Thy Practice, James & Rachel will share their insights on how to use social media like Facebook, Linkedin, Google, and Groupon, as well as email-based outreach to help empower patients toward better health. “Health and healing really happen outside the walls of your clinic, in your patients homes, in their workplaces, in their ordinary lives. Make it easy for your patients to make better choices during the vast amount of time they’re not in your office.”

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