July 29, 2020
Help us serve our local small businesses:
Over the upcoming year we want to focus our growth potential on helping local small businesses learn about providing membership primary care to their employees in a tax advantaged way.
Our patient membership growth at Wise Patient for the trailing 12 months is 79.7%. Even during the pandemic, membership growth from February to present is 21.5%. We could not have accomplished this without your thoughtful support and critical feedback. Thank you! During Wise Patient’s growth we try to protect the quality of your care by limiting our physicians’ roster size. Currently Rachel and Sam have full rosters and Naomi – our newest recruit – is filling faster than expected. As physicians, our relationships with you, our patient family, are closer to what we imagined when we first walked into medical school, and that is a career pick-me-up!
Currently, new members sign up as individuals. We believe our care delivery model can be equally successful for small employers who want to do well by their employees, providing them a doctor in their pocket. We know from experience that when primary care is paid for on a per-member-per-month basis (aka Direct Primary Care, or DPC), better communication between patients and doctors happens, patients are able to reach more of their health goals, and the cost curve bends favorably through lower need for speciality and emergent care. Hurried doctors don’t treat people. Relationships do.
The tailwinds for small employers to offer membership primary care as an employment benefit have recently become stronger:
- Actuarial data. The Society of Actuaries recently commissioned the prominent Milliman Consulting Firm to perform the first bona fide actuarial study of DPC. It was published in May: https://www.dpcare.org/actuaries-report. Among other findings, DPC members had lower risk-adjusted claim costs, fewer ER visits/costs, and 25% lower hospital admissions.
- IRS acknowledgement of DPC. The IRS issued a regulation proposal 6/8/2020 (https://tinyurl.com/yypuznzt) which will make Direct Primary Care (DPC) an eligible medical expense under Section 213(d) and allow workers to use ordinary HRAs (and small business QSEHRAs, and FSAs) to pay their monthly DPC membership fee.
- State laws in support of DPC. Thirty-four states now have laws (or codified guidance with the same force as law) that describe and regulate DPC on its merits and make it clear that DPC is not a health insurance product but rather it is healthcare! Proudly, Washington State’s RCW 48.150 (https://tinyurl.com/y5dz93bl) was the first of such laws passed.
Headwinds still exist:
- Health insurance brokers are typically paid on commission by the insurance company they contract to the business. Occasionally, even inadvertently, this may influence their recommendations to small business owners.
- Very small businesses who feel unable to provide an ACA health insurance plan (and may not be required to on the basis of their size) may not realize there are tax advantaged ways for them to provide membership primary care to their employees as a stand-alone benefit. As one example, small employers who don’t offer group health coverage to their employees can help employees pay for medical expenses through a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA).
- Leading a small business is hectic (to say the least during a pandemic). The effort it takes to initiate or change a group health insurance plan can feel overwhelming, and often involves an insurance broker who may be less familiar with DPC and how to link it to a health insurance product in a cost-efficient way.
We believe the future of primary care has arrived in the form of membership primary care. How we treat our patients at Wise Patient has much to thank for your feedback along the way. If you know of any small business owners, CPAs, health insurance brokers, or other advisors to small businesses you believe would benefit from joining this conversation, we’d be happy to connect with them!
Giving Smoke Breaks a Break
Times of increased stress can be hard times to take on something like smoking cessation. At the same time, big changes invite a reshuffling, prioritizing and commitment to change. This is as good a time as any to quit smoking, so if you or someone you know is ready to take on smoking cessation, here are some steps to consider.
Many people find they need to attempt to quit smoking several times before they quit for good. If that is you, you have probably learned from the past things that may have been barriers to quitting. For some people it may be that someone else in the household is smoking, or that they had formed habits around a cigarette with a cup of coffee or a bottle of wine that are hard to shake. Sometimes it is the weight gain that frequently accompanies quitting smoking. Whatever you learned, you will be armed with that knowledge this time and be able to come up with some strategies for avoiding those pitfalls this time around. What plans could you put in place that would help you this time around? What would be some strategies to avoid those triggers? There is research that shows that patients who choose to quit smoking abruptly have a higher likelihood of success than those who chose to use a slow taper. So, once you have come up with some strategies to avoid pitfalls, it is best to establish a quit date.
There are medications that can improve your chances of successfully quitting. Among those are nicotine replacement therapies (NRTs). NRTs can improve your chances of quitting by 50-60%. These will blunt the effects of the withdrawal your body will be experiencing from decreased nicotine so that you can gradually taper down. There are many ways for the nicotine to get into your bloodstream. It can also be helpful to think about “long acting” and “short acting” nicotine replacement. Long acting nicotine replacement comes in the form of the nicotine patch and it delivers a slow steady amount of nicotine. The nicotine patch comes in 21mg, 14mg and 7mg doses. In general, if you smoke >10 cigarettes per day, you should start with the 21mg patch. If you smoke <10, you would start with the 14 patch. You would then taper down from the starting point as you are able. The patch is applied daily and kept on for 24 hours. Sometimes, it can cause vivid dreams and you may choose to take it off at night and reapply in the morning. The patch can cause skin irritation, so it is better to rotate sites. Short acting nicotine is delivered intermittently throughout the day through lozenges, gum, nasal sprays or inhalers (although the last two are not used as much). Short acting NRTs get best results when combined with a long acting NRT like the patch. Nicotine gum can be effective, but has to be used correctly. It is not meant to be chewed like gum in spite of its name. The correct use of the nicotine gum is to “park” it between cheek and teeth until the peppery taste of nicotine wears off, then to re-chew and re-park. The nicotine gets absorbed through the buccal mucosa. If you chew it without parking it next to your cheek, it doesn’t get absorbed and swallowing it will lead to stomach upset. The mini lozenges are a newer and effective way to deliver short acting nicotine. There are two doses 2mg and 4mg and they can be used every 1-2 hours. Although some people recommend everyone starting with the 4mg lozenges, other people reserve those for people who have their first cigarette within 30 minutes of waking. It is best to use them to avoid developing cravings, rather than to deal with cravings once they happen.
There are two main medications that can increase your likelihood of success with quitting smoking in addition to NRTs. Those are Varenicline (Chantix) and Bupropion (Wellbutrin). Varenicline about triples odds of quitting when compared to placebo. It was designed specifically to help patients quit smoking. It works as both a nicotine receptor agonist and antagonist. It binds to nicotine receptors in the brain both blocking the reinforcing effects of nicotine from cigarettes and causing the release of dopamine and other neurotransmitters that mimic the effects of nicotine on the brain. So, your brain thinks you already just had a cigarette. The side effects include nausea and vivid dreams. Chantix should be started about 1 week before your quit date. You start at a lower dose and titrate up. When you get a prescription for Chantix, you will get a starter pack with the correct dosing and timing of medications to start with. Eventually, you will take it daily for 3-6 months. Although there were some early concerns with Chantix causing psychiatric issues and an early black box warning, subsequent studies did not find this association and the warning was lifted. Wellbutrin is the other medication commonly used for smoking cessation, although it is less effective than Chantix. It can be associated with an increase in anxiety in about 15% of patients, but may help to diminish the weight gain associated with smoking cessation. it can also cause insomnia and dry mouth.
Finally, e-cigarettes or “vaping”. Although there was hope in the beginning that these might be a way to bridge people toward smoking cessation, studies show that e-cigarettes or vaping are far inferior to other NRT strategies for quitting smoking and have other known and unknown side effects. Many people who start vaping also continue to smoke cigarettes. We do not recommend this as a strategy to quit smoking.
There are support systems available such as 1-800-QUIT-NOW, www.smokefree.gov. and you can reach out to us anytime for advice and assistance.
Wilson, H., & Sherman, S. (2016). In adults, quitting smoking abruptly improved abstinence more than quitting gradually. Annals of internal medicine, 165(2), JC3-JC3.
Unmasking the Details
At Wise Patient, we are continuing to encourage everyone to keep wearing masks, however, we wanted to take the time to discuss some important caveats to this. We want to discourage the use of face masks with exhaust valves. While these exhaust valves allow air to escape while breathing and provide more comfort, it also means that viral particles can be exhaled out and potentially cause further spread of COVID-19. With this information, many places around the country such as doctor’s offices are starting to ban these masks. Face shields, which can provide extra protection while wearing a mask, are less effective when worn alone. A study in 2014 showed that while face shields can provide protection against respiratory droplets/particles, smaller particles that remain airborne can still be inhaled as they are able to flow through a face shield. Because of this, it’s discouraged to wear a face shield by itself with no mask underneath. As we continue in this pandemic, make sure that you are being safe and protecting both yourself and others from COVID-19.