I recommended that she call her MCO for primary care assignment and appointment this week, if possible. I also recommended going to urgent care or the emergency department (ED) for treatment of the cellulitis on her leg. She started crying and said the people (nurses and doctors included) in the ED and at urgent care are “so mean.” At this point, I wanted to take her back to my direct primary care office to treat her addiction and cellulitis and arrange follow up with her surgeon for valve replacement, but Kentucky Medicaid MCOs will not honor referrals by a nonparticipating physician.
There are several steps we need to take in this country to humanely address the opioid epidemic and fix our broken healthcare system.
First, we should integrate behavioral/mental healthcare with medical care. Family physicians are well trained to care for complicated patients, but all physicians need more training in screening for, diagnosing and treating substance use disorders. Second, we must reduce the stigma surrounding addiction and recognize addiction as a chronic relapsing brain disease. Treating addiction is similar to treating other chronic diseases, requiring lifelong monitoring, with intermittent group and individual counseling tailored to the individual. Third, stop knee jerk regulations and de-regulate the current healthcare system. Allow people to purchase affordable health insurance that is truly “insurance,” covering unexpected medical events, and pair this coverage with Direct Primary Care, which we know is affordable, decreases ER and urgent care utilization, and decreases specialty referral.
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Managed care Medicaid is an expensive solution, which is very costly for taxpayers while allowing MCOs to enjoy record profits at the expense of quality for patients. If a person with Medicaid would like to pay directly for care, he/she should be able to do so without penalty. Physicians should be allowed to opt out of Medicaid, just as we are with Medicare—which would enable physicians to refer prescribe, and order imaging for a patient paying directly for services. Fourth, physicians should take their oath to heart and treat all patients with respect.
If physicians in the emergency department are burnt out from dealing with addicts, they should learn more about addiction and ideally learn to treat opioid addiction and withdrawal. Initiating buprenorphine/naloxone in the emergency department with referral to a community provider has shown promise in studies.
As politicians and health policy experts continue to focus on coverage as the goal to improving health in the U.S., several direct care physicians are taking steps to provide affordable care for people, including, in my case, treatment for opioid dependence. Unfortunately, onerous federal and state legislation limits how many people with this lethal, costly chronic disease I can treat.
It’s time for practical physicians and entrepreneurs to fight for real reform, with low cost direct care for relatively inexpensive outpatient care supplemented by true catastrophic insurance for unexpected care, such as hospitalization. Medicare and Medicaid reform should include patient-centered solutions, such as personal accounts similar to health savings accounts for outpatient care that would encourage patients to shop for best prices and excellent services.
Dr. Molly Rutherford started her own Direct Primary Care practice, Bluegrass Family Wellness, in Crestwood Kentucky in 2015. She is Board Certified in Family Medicine and Addiction Medicine and is dedicated to providing comprehensive care at an affordable price without the administrative burden and overhead associated with the current healthcare system. She was born and raised in Virginia, graduated from Virginia Tech in 1992, Johns Hopkins University with an MPH in 1999, Eastern Virginia Medical School in 2003, and completed residency at Portsmouth Family Medicine in 2006. She lives with her husband and two children in La Grange, KY.