ACA (“Obamacare”) Questions (sort of) Answered

I’m getting a lot of questions about this now that we’re nearing the end of open enrollment (March 31, 2014).  Here is some basic information that may help.  To be clear, I don’t think the ACA solves all our problems.  Affordable insurance is not the same thing as affordable medical care.  Many people are still spending a lot of money for insurance they are hoping to never use because of a uselessly high deductible.  But it’s progress.  I’m hoping to never again recommend to a patient that they declare bankruptcy because of a twist of fate that landed them in the hospital for a few days.

Nothing significant is changing at my practice.  Medicaid has been expanded to include everyone under a certain income level (see below) so I am accepting Medicaid from current patients who now qualify.  People have asked why I’m not accepting new patients with Medicaid…it’s nothing against Medicaid, I assure you!  I just want to make sure I have room in my practice for people who are still uninsured or who have ridiculously high deductibles so still don’t have access to affordable care.  If you know someone who would benefit from joining the community ($30 a month for each of the first two members of a household and $15 a month for each additional member), please pass on my information to them.

Here’s some information about the Affordable Care Act that many people don’t understand:

1. While we are all expected to have coverage, we are not all expected to pay $1000 a month to get it.  How much a family pays depends on that family’s FPL (what percent of the federal poverty level they have gross income).  Here is a chart of FPL:  Notice that the larger the family, the higher the income for a particular percent.  A baby in utero counts as an additional family member (so a couple with two kids and a baby on the way will be a family of five).  This is based on gross income in order to make it fair for everyone.  It’s basically adjusted gross income (line 36 on the 1040) but there are a few modifications that can be made so it’s called MAGI (modified adjusted gross income).  The MAGI is higher and includes things like student loan interest and IRA contributions that would not be in the AGI.  If someone is right on the border of getting or not getting a benefit they should discuss it with someone more knowledgeable than I.
2. If a family or individual makes less than 133% of the FPL they automatically qualify for Medicaid.  The entire family, not just mom, not just the kids. 
3. If a family or individual makes between 133% and 250% of the FPL they get both premium subsidies (to help pay their insurance premium) and cost sharing subsidies (to improve the value of the plan by decreasing maximum out of pocket/deductible/coinsurance/copay).  Kids and pregnant women in this group still generally qualify for CHP+.
4. If a family or individual makes between 250% and 400% of the FPL they get just the premium subsidy (to help pay their insurance premium).
5. If a family or individual makes over 400% of the FPL they don’t get any subsidy and should refrain from whining because they are better off than almost everyone I know.  🙂
6. The amount a family or individual pays is figured as a percent of their income and that percent is less for lower incomes and more for higher incomes.  With the premium subsidy, the subsidy amount is based on what a family would pay for the second cheapest silver level plan; however, they can take that money and use it to buy whatever plan they want.  If they buy a bronze plan they’ll pay less; if they buy a gold plan they’ll pay more.
7. All plans, even the cheapest bronze level plans. are required to cover preventative care (such as paps) without a copay/coinsurance.  That said, they will do everything they can to pay for as little as possible. 🙂
Here’s a calculator where you can find out about how much you can expect to receive in subsidy and how much you can expect to pay for a silver level plan per month:
Here’s where you can go shopping for plans:

 One thing that has continued to confuse people is that everyone at a particular FPL is expected to pay the same amount for insurance whether they are buying insurance for one person or for eight family members.  What this means is that you may be in the income bracket where you should get a subsidy but you don’t, or you get less than someone else you know.  It’s because insurance is more expensive for larger families and for older adults.  If you are young and healthy and buying insurance for just one person, you may be paying less for insurance than the legal cut-off for your income.  This is especially true here in Colorado where people are generally healthier than other states so our insurance is more affordable to begin with.

If you need help figuring this out, I’d recommend you go to an assistance site for help.  The closest I know of is at DoctorsCare in Littleton.

One Reason I Love the Membership Model

Did you know that many primary care offices have a rule that if a question takes more than five minutes to answer over the phone, the patient has to schedule an appointment.  Do you know why?  Because that is time a doctor is spending that he or she isn’t getting paid for.  In a medical office, the physician is the goose that lays the golden egg…if the time a physician spends isn’t being paid by someone, then the practice as a whole and everyone who works there is that much poorer for it.

Here’s a chart showing the average time a primary care doctor spends in an appointment with a patient:

From Medscape Survey of Family Physicians 2013

From Medscape Survey of Family Physicians 2013

I usually spend 10-15 minutes on the phone with a member.  If I worked in a normal office, that would be money down the drain.  With the membership model, I don’t have to think about it.  If it’s a question that can be answered over the phone, I answer it over the phone.  If I need to see someone in person, we schedule an appointment (30-60 minutes) instead.

This month I’m accepting Medicaid for all current patients who now qualify.  I was surprised to notice my mindset changing automatically.  Have a question that requires a long conversation?  Better come in for an appointment…the better to pay me for, my dear.  I HATE thinking that way about patient care.  That’s not what I’m here for.  Now, please don’t get apologetic about having Medicaid.  You are entitled to it and I am accepting it for current patients because I support the Medicaid expansion.  But please forgive me when I ask you to come in for an appointment to discuss something…Medicaid and other insurers don’t consider a phone call to be “billable time.”

Health Insurance Exchange

We’ve all heard about the Mandate to buy insurance.  We all know that’s starting soon.  But clear information about how this actually works is hard to find.

So how does buying and using insurance work?

  1. Everyone can browse through health insurance options through the Health Insurance Exchange, now called Connect for Health Colorado.  This will be most helpful for small businesses and people who are not able to obtain insurance through their jobs.  The Health Exchange is an improvement over the current method of using a broker because you can easily compare your different options.  The Exchange will also automatically screen you to see if you qualify for Medicaid, CHP+, etc.  Approximately 10% of people who are uninsured (including children) are estimated to be eligible for one of these programs.  Everyone else using the Exchange will have the opportunity to choose from various plans that provide various levels of coverage.
  2. If you are unable to obtain “affordable” insurance (please read below for an explanation of affordable)* through your employer, you will be provided with an up-front subsidy that can be used to buy health insurance through the exchange.  Basically, you’ll log in to the exchange, enter your information, and an automatic payment from the government to the insurance company will cover a certain amount of your premium.  This subsidy is technically a tax credit, decreasing the amount of taxes you owe.**  Use this calculator to play around with this.
  3. Your use your insurance.  See the next installments for an explanation of insurance terms and how this affects how it’s used.

*Unfortunately “affordable” insurance is defined as insurance that costs less than 9.5% of your W-2 income for INDIVIDUAL coverage.  Even if you spend 50% of your income in order to insure your family, this is considered affordable so long as it is still 9.5% or less of your income to insure just the employed individual.  If you are in this situation, you can still shop for insurance on the insurance exchange but you will not be eligible for the tax credit.  Some families will find it more affordable to buy a separate plan for the rest of the family.

**What I can’t figure out about this is that the supposed tax credit can be more than the amount of taxes you actually owe.  For instance, I entered $36,000 into this calculator to determine the expected credit for a sample family of four.  The expected tax credit is $9603.  If you go to this table of tax rates and deductions for 2013 (in other words, the rates that will be used for preparing your taxes a year from now), you will see that this family of four has a standardized deduction of $12,200.  I’m ignoring all the other deductions at the moment to make this simple.  So let’s just say their taxable income is then $23,800 (gross income minus standardized deduction).  Using the tax table, the total tax this family owes $2677 in taxes.  So their tax credit is almost $7000 more than their actual taxes.   I can’t figure out whether any of this is billed to the family.  I would hope not.  (Scroll to the bottom of page 2 of this document from the Department of the Treasury for where I found this information.)  ADDENDUM: I think I found the answer.  The health insurance tax credit is what is referred to as “fully refundable,” which means that it can actually reduce your taxes to below zero and be paid out.  So the only real problem I see with this is that families who have been using their tax refund to pay off debt or invest in a used car will now not receive any refund.


Recently, my husband noticed that Costco was carrying a sunscreen with an amazingly high SPF: 100+.  This seems on the surface to be a great idea.  More protection is better, right?  Unfortunately, sunscreen isn’t all it’s cracked up to be.  I definitely want you to protect yourself from the sun!  But don’t slather on some SPF 100+ sunscreen and then blithely rotisserie yourself in our Colorado sunshine.  What can you do to protect your family?

1. Don’t count on just the sunscreen.  Use other sensible measures, such as staying out of the sun between 10am and 2pm, wearing clothes that provide shade, and wearing sunglasses.  Here are Skin Deep’s Top Tips.

2. Buy safe sunscreen.  Many sunscreens contain numerous questionable ingredients.  Sprays seem easy, but aerosolized chemicals can get into the lungs or eyes.  Here are Skin Deep’s Best and Worstsunscreens for 2012.

3. Be informed.  Remember that manufacturers are out there to make money, not to help you!  Skin Deep’s Surprising Truths About Sunscreen.

So what do I do for my family?  We spend a lot of time in the shade or wear long sleeves and hats, we use one of the products off of Skin Deep’s Top Sunscreens list, and we do regular skin checks to watch for concerning spots.

Medical Prevention: More Natural Than You Thought

As many of you know, I am a huge proponent of lifestyle as the first “treatment” we all need.  Science agrees.  Here’s what the National Institute of Health has to say on the matter:

Only 5–10% of all cancer cases can be attributed to genetic defects, whereas the remaining 90–95% have their roots in the environment and lifestyle. The lifestyle factors include cigarette smoking, diet (fried foods, red meat), alcohol, sun exposure, environmental pollutants, infections, stress, obesity, and physical inactivity. The evidence indicates that of all cancer-related deaths, almost 25–30% are due to tobacco, as many as 30–35% are linked to diet, about 15–20% are due to infections, and the remaining percentage are due to other factors like radiation, stress, physical activity, environmental pollutants etc.

And the Harvard School of Public Health states that a whopping 82% of heart attacks are preventable through lifestyle.  According to the National Stroke Association, up to 80% of strokes are preventable, though they don’t quantify how much of the prevention is with lifestyle and how much is medication.

This is not to blame anyone who has had something terrible happen.  I never condone guilt, self-blame, etc.  More about my own experiences causing my own major medical emergency another time, but today I just want to say that for any of us, knowledge is power.  Once we know what we can do to prevent bad things from happening, we can act on that knowledge.  That said, I have known many people who “did everything right” and still had something bad happen…what gives?  Well, there are the genetic factors.  There are all the bad things we can’t avoid.  There are flukes.  We’ve all got to go sometime.

So what can we all do to increase our chances of enjoying a long active life free of cancer, heart disease, and stroke?

  • Quit smoking.  This is the single best thing you can do for your health.
  • Exercise.  There is so much to do here in Colorado with our beautiful weather.
  • Eat well.  You don’t need to buy a book or sign up for a specific plan.  We all know what we need to be doing…more fruits and vegetables, fish or grass fed beef in place of Big Macs.
  • Avoid environmental pollutants.  For many of us, that includes avoiding pesticides and hormones in our food whenever possible.  If you can’t buy everything organic, at least avoid the Dirty Dozen.
  • Limit sexual partners.  One in six cancers is caused by infection.  Three of those infections, HPV, Hepatitis B, and Hepatitis C, are commonly spread sexually.  Condoms are better than “unprotected sex” but they are not completely effective at preventing infection.  They are about 85% effective at preventing pregnancy and hepatitis, 50% effective at preventing gonorrhea and chlamydia, and even less effective at preventing HPV.  Monogamy is the safest sex.  Not just “serial monogamy” (you can still acquire and share infections), lifetime monogamy (or as close as you can get).
  • Don’t share needles.  While you’re at it, don’t do drugs.
How will you incorporate these changes into your life?  Everyone will choose differently.  I’ve known people who gave up smoking by taking up knitting.  Counseling can help clarify why we are holding on to bad habits…whether those are food, sex, or a sedentary lifestyle.
Me, I like to garden for the mental benefits, the exercise, and the good food.  I know there are no nasty chemicals in the food I grow myself.  If you want the good food without the gardening, or can’t fit cattle or pigs in your backyard, check out Denver Urban Homesteading.  At DUH, you can be certain there are no pesticides or extra hormones added to your food.  Another way to increase your exercise while improving the world is to bike or walk instead of driving.
I always stress BABY STEPS to people.  You can’t change everything you do overnight.  Make small easy changes and they will accumulate over time.

Mood 24/7

We are, as a species, notoriously bad at stepping back and observing our fluctuating emotions in a rational way.  I know, I know, emotional and rational are virtually opposites.  But this makes the difficulty of tracking mood over time notoriously difficult.  When I feel down, I feel as if I’ve never really been happy.  When I am happy, I can hardly remember a time I wasn’t.  So when I sit down and try to figure out whether or not something is helping–counseling, exercise, nutrition, hobbies, supplements, bright lights, medication–how am I to know for sure?  There is a nifty new cell phone app that is free and confidential that will send you a text once a day (at a time you choose) asking about your mood and then record the information on your own secure mood-tracking site.  You can then allow access to any of your providers.  Or you can do it just for your own records.

To sign up go to Mood 24/7.

If you want to allow me access to your mood log, my user ID is drrobincsfm (spaced out that would read dr robin csfm).

Concierge Medicine Compared to CSFM

Because half of my goal in opening CSFM is to provide AFFORDABLE medical care, I want to take a moment to answer a question I have received several times: What makes CSFM different from concierge medicine?  Isn’t this just another get-rich-quick scheme?  I have a whole other group asking me, how can you even afford to pay rent with this model?  I find it amusing that my finances concern people so much in both directions, but as my goal is to be community supported, I think it only appropriate that I explain to my community how this works.  Today, I’ll start with explaining how we compare to concierge medicine.  Another day, I’ll explain how I’m able to make ends meet.  I also want to discuss how I define QUALITY medical care, since that is the first half of my goal.

Let’s start by talking similarities.  Obviously, there are enough of them that people are asking.  The one similarity that has caused the questions is the membership option for care.  You’ll recall that you can become a CSFM member for $30 a month ($360 a year) for the first two members of the household and $15 a month ($180 a year) for the rest of the members of the household.  Concierge practices also charge a membership fee.

Concierge practices and I are all interested in providing high-quality, personal care.  You’ll notice that I answer my own phone or it goes to my own voicemail: no receptionists, no nurses.  If you need urgent care, you can page me directly.  In my case, it is a cost-cutting measure to allow me to lower my overhead and pass on the savings to those who may not otherwise be able to afford medical care.  For concierge practices, it’s part of the “value added.”  Nonetheless, it is a similarity.  We also both provide longer appointment times.  That’s because we all enjoy taking the time to get to know our clients/patients and make sure we provide the best care possible.

I did an online search for “concierge medicine denver” and here are the first five practices that came up (they are not all in Denver, but all are along the Front Range).  I copied bits from their websites to illustrate the differences.  Concierge practices typically charge much higher membership fees, and all of those that charge lower membership fees also charge a hefty price per appointment, and a different price for different types of appointments.  They typically will not see you unless you are a member…you must belong to the club, so to speak.

1. Advanced Integrative Medicine.  ”This service is provided for a fixed annual fee of $1,500 per patient, $2,500 per couple and $250 per child (18 years and younger).”  That would be the first big difference.  Price of membership.

2. Dr. Kevin Lutz.  ”For $3,000 a year (just $250 monthly), Dr. Lutz and his staff provide comprehensive and proactive care. Your health insurance still covers prescriptions, hospitalizations, lab and radiology tests, and care from other doctors.”  That price thing again.  The assumption is that your insurance foots the bills for everything else.  As you know, one of the huge benefits in my practice is that I assume you are paying out of pocket so run your labs through my account (at a huge discount) and help you find affordable medications and imaging whenever possible.

3. Flatiron Premier Medicine.   ”Yes.  Your insurance company will be billed directly for office visits with Dr. Erik Mondrows.  If your insurance carrier/plan requires a co-pay, Dr. Erik Mondrow is required to collect it. Office visit charges, with the exception of your Annual Comprehensive Medical examination, are not included in your annual fee.”  Many concierge doctors are charging the fee just for you to belong, and they also charge for visits on top of that.  This doctor does not say how much the appointments themselves are.

4. My Family Doctor.  ”For $350 a year, patients receive: A 1-hour comprehensive annual physical exam with age and sex-appropriate screening tests (e.g. pelvic exam, breast exam, prostate exam, etc.).  Cost of pap smear pathology fees and lab fees are not included.  A discounted rate of 30% on office visits which are charged based on time spent by the physician.  E.g.  a member can expect to pay $110 for a 30 minute visit, whereas a nonmember would pay $165 for a 30 minute visit.”  This office actually lists their prices.  $110 or $165 for a 30 minutes visit are typical costs for any doctor’s office and are charged in addition to the annual fee.

5. Pinnacle Family Medicine.  ”Annual Access Fee   $360/adult $240/minor  Office Visits  •15 minutes   $85  •30 minutes $110 •45 minutes   $150  •60 minutes  $200.”  This is her silver level option.  The membership prices go up from there.  Again, there is that additional charge per visit.

I am not criticizing the concierge physicians for their decisions any more than I criticize friends for going into business or retail instead of teaching or social work.  We each have to make decisions according to our own values, and I’m sure these physicians provide excellent care; however, our goals and values are different.

The goal of my “membership” is to allow patients to budget their primary care over the course of the year and then not limit themselves to only coming in if they absolutely have to.  Most uninsured and underinsured people I know won’t see a doctor unless they absolutely must because of the cost of the appointment.  By having appointments without a separate charge for each appointment, I’m hoping everyone will come in when they feel they need to come in, instead of waiting.  I want everyone to get things (concerning skin spots, ongoing cough, blood pressure creeping up, low moods, whatever) taken care of instead of just living with them.  Some studies have shown that even a $10 copay prevents insured people from seeing their doctor.  These are people who are often already paying hundreds of dollars a month for insurance.

I also want the prices to be transparent.  Many of us have had the experience of going into a doctor’s appointment for one concern and coming out with several other issues addressed.  In a typical practice, you would be charged more because the visit was more complicated and took longer.  Me, I expect most people to have more than one concern and I plan accordingly…but don’t penalize you by raising the price for my time.

Ultimately, it comes down the goal of CSFM.  My primary goal is to provide quality, affordable primary care for families and individuals regardless of their ability to acquire insurance. Yeah, I need to pay the bills and feed my family, but I don’t need a big fancy house (I live in a little bungalow a few blocks from the practice), a new car (I’m proud of our one car and its 100K miles), or long vacations (besides, it would be hard to find someone to take care of the chickens for more than a few days).  What I do need is to find meaning in my work.  If I’m going to have to be away from my family during the day, I’d rather spend my time doing this than anything else.