A Difficult Choice

It is with deep frustration and regret that I announce Medicare has opted to discontinue paying ThriveAPC for home visits, effective April 1, 2022. Reimbursement from Medicare for Telemedicine billing claims has also significantly been scaled back

These adjustments to reimbursement for my practice have been instituted with parameters that are too complex to be managed without a professional billing service.  Whereas going that route would fly in the face of why I opened my own practice to begin with, which was to reintroduce simplicity and transparency to the workings of my profession as a Primary Care Physician.

Once upon a time, a “family doctor,” or “personal physician” had meaning; it evoked the image of a friendly face, black bag in hand, seated bedside in the home of an individual who is ill.  Bringing this imagery back to life in my patients’ experiences has been the joy of my career. 

However, there’s a reason it has become exceedingly rare for physicians to perform home visits.  It is this nagging aspect of operating an organization, known as “overhead.”

No one likes to think of a physician practice as a “business.”  But as a professional seeking to practice medicine, I have a choice.  I can hop aboard current conventions and be hired into a large corporate organization, or I can try to go it on my own.  I’ve done the “large multispecialty group practice” thing.  I chose independence, because I was tired of being professionally handcuffed by a system that claimed to share my values but overtly did not.  Five years ago, I stepped out of what felt like the Empire’s Death Star into an abyss of emptiness where I repeatedly found myself face-to-face with maleficent meteors and consumptive forces of all shapes and sizes, myself merely a tiny traveler now unprotected by the “system” that had it all figured out in advance, while I found myself trying to build a vessel from scratch while on the fly.  Failure threatened from every angle, time and again.

But I’ve never regretted the decision.  To choose freedom. 

Any day of the week, I would still prefer to face all demons that threaten to consume me with my own armament of ingenuity, instinct and altruism than subject myself to manipulation within a system that usurps these virtues to make me a pawn.  I trained too hard for too long and sacrificed too much of my youth to give in to that now.

Ironically, the “great abyss” of unvarnished society is not actually an empty space at all.  Instead, it is a tangled morass of human nature, contrived institutions, intelligent machinery, and countless other nameless, faceless influences that flow and interconnect into a sea of obstacles.  The analogy of truth is much easier to conceptualize as an ocean, rather than outer space.  At the terrestrial level where we live, “monsters of the deep” do exist.  And all too often, we deify them.

Many of these influential deities exist as laws and mores, and I accept that I am subject to them.  I am bound to an oath I took upon graduating medical school.  I am bound by law to protect the privacy of my patients.  I am also bound by shrewd sensibility to script contracts between myself and any individuals or entities with whom I engage dealings, whether it be the owner of the property I occupy, the laboratory that processes blood and urine specimens I submit, the insurance agencies that promise to protect my assets if someone slips and falls while under my auspices… etc.

I understand social and legal norms, and remain adherent to such commitments.  Altogether, they form a fairly rigid structure within which I can practice my profession.  However, the structure is still far less rigid than the corporate system that contained me as an employee. 

And because I am less duty-bound by employment contract to generate revenue with specific activities as a physician… I have been able to be a better physician.  I sit and chat with my patients until we develop trust.  I go to bedsides with a black bag in hand to see people who are too sick to make it to the office to come see me. 

I am still responsible for the operational costs of running my practice, and what I’ve gotten paid for doing what I do barely pays the bills.  In fact, there have been so many instances where it did *not* pay the bills, that I’ve restructured and restructured to stay open – and through it all, through novel practice models that do not translate to my geography, through a pandemic, through instability of staff turnover… we’re still here.  

Seeing patients in their own homes.  “Old school” style.  I’ve taken pride in it.

But this activity has been deemed by algorithmic calculations to be too irregular relative to the activities of my local peers to be valuable.

Please allow me to explain a few frequently unknown details of how payment for medical care works.

At this juncture, Medicare’s permitted reimbursement rate for a standard medical home visit in the local area is $139.  Reimbursement for a standard office visit is $144.  Medical home visits not only take more time and resources on account of driving, navigating entry procedures at living facilities and so forth, but also are performed generally on patients that are highly medically complex, amping up the effort relative to a typical office patient, and often resulting in a high volume of “post-visit” work such as generating orders for testing/treatment through a variety of auxiliary services and channels, communicating with specialists or other service providers such as nurses, case managers, pharmacies, therapists, etc.  None of the “post-visit” work is considered “billable activity” by Medicare.  All of that labor is assumed to be “covered” under the visit reimbursement.

Whereas it is also worthwhile to note that Medicare only covers on average 79% of the billed amount, meaning that of a $139 billing claim sent to Medicare, ThriveAPC only receives $111 *from* Medicare when the bill is fully processed and approved.  There is a 20% cost-sharing assumption for most Medicare patients.  Supplemental health insurance plans sometimes pay for this 20% co-insurance fee.  Sometimes, but not always.

Whatever labor is performed by ThriveAPC that remains unpaid by Medicare or supplemental health plans, to date we have simply written off, on account of a strict code to avoid sending “surprise bills” to patients.  Our objective is not to “make money”, but to serve the community as effectively as possible.

However, unless we are solvent as an entity, we will be unable to serve the community.  In order to provide the top-notch medical care we take pride in, we have to *exist*.  And we unfortunately cannot exist if we cannot cover operational costs.

We have taken pride in our commitment to writing off co-pay and co-insurance charges typically charged to patients in association with standard Medicare claims.  Unfortunately, due to these decreases in Medicare reimbursement, we are no longer able to sustain operations while doing this.

Unfortunately, even “patient care” is becoming increasingly encumbered for Primary Care Physicians.  Government forms to be manually filled out in order to justify reasonable care through ancillary providers or alternative coverage for such care such as through Veterans benefits or Social Security/Disability (which is separate from Medicare as an entity), Prior Authorizations with endless clinical questions and requiring documentation that would be obviously archived. 

It is all understandable when it breaks down.  There has been too much fraud committed in the past, and all these ancillary providers are trying to protect themselves from fraudulent activity.  But those of us seeking to follow all the rules are the ones who are handcuffed and morally harmed with the logistical beatdown, then blamed by patients for sluggish response.

Advice from so many angles insists that I drop the fight and adhere to convention.  Get a billing service.  Contract with the insurance companies (BCBS, Aetna, United, Anthem, etc).

But I have a firm policy:  Never accept support from someone who has the power to break you by disappearing.

The following changes will be made in our billing/pricing scheme, effective September 1, 2022, details to be published in the near future:

  1. Membership Fees, Pay-As-You-Go Office Visit Fees and Home Visit Distance Fees will increase across the board, although patients who have maintained loyal membership for a certain number of years will be protected from any increases in recurring (monthly or annual) membership rates.
  2. Co-insurance charges for non-member Medicare patients will be payable at the time of a visit.  Supplemental insurance plans will likely cover/reimburse this cost to the patient.
  3. Medical Marijuana certification and renewal will be more readily available but will incur separate charges even for member patients.  Discounts will apply for member patients and Medicare beneficiaries.

I have faith that there are enough individuals and families out there who are open-minded enough to understand why I run Thrive Adult Primary Care the way I do, and to continue using our services in spite of these changes. Certainly, those who are not in alignment are always welcome to seek services among my amazing colleagues in the local area, albeit those who are struggling with different elements of a system that disables our hard-earned professional liberties. The population of responsible, well-educated medical professionals available to take on patients is dwindling rapidly, and what I describe here is only a small percentage of the reasons as to why.

Please accept my best wishes to all. My sincerest hopes for a brighter future extend profusely.


Dear Patients and Caregivers,

This message is being sent as a notice of my upcoming family vacation:

***I will be away from Saturday February 19, 2022 until Sunday February 27, 2022***

No patient visits will be performed that week, although phones will continue to be monitored regularly during our office hours of Monday thru Wednesday, 8:30am – 3:30pm as our amazing staff, Trish (Clinical Manager) and Lisa (Administrator) will continue working in my absence. THE OFFICE WILL BE FULLY CLOSED THURSDAY 2/24 and FRIDAY 2/25.

PLEASE AVOID USING EMAIL to reach out for medical questions or concerns. You will receive much more timely attention by calling our Office Line at (774) 318-4205 and leaving a voicemail if there is no answer.

Medical coverage will be provided by a respected colleague whose contact information will be posted in our Office Voicemail during that week. For serious matters of urgent priority, it is strongly advisable to be evaluated promptly in an Urgent Care Center or Emergency Department.

Please stay safe and warm!

Dr M 🙂

Mary A. Medeiros, MD, MPH
Thrive Adult Primary Care
835 W Central St, Ste 4 | Franklin, MA 02038
Phone: 774-318-4205
Email: mary.medeiros@thriveapc.com
Web: http://www.thriveapc.org

The Anatomic Mind-Body Connection

I have often wondered why we talk about a “mind-body connection” as if it were some vague, ethereal, spiritual thing. Last I checked, everyone’s head is attached to their torso. And the wiring is rather specific, too. Allow me to show you.

Exposed! –A Doc’s Perspective

The ‘fun’ has once again begun, and between the barrage of exposures, possible exposures, questionable symptoms, and doubts and fears around vaccination, I am being repeatedly asked for advice. It only seems apropos to make a basic statement perhaps lending insight to the most common situations surrounding COVID-19 these days.

Before you read the following, please allow me to be ABSOLUTELY CLEAR about something: “There is one thing that we know, which is that we know nothing.” All statements I make are based on SOUND REASON in keeping with my medical background, which, beyond medical school, includes 5 years of post-graduate training, and nearly 15 years of independent practice in multiple settings which not only include private practice Primary Care but also tertiary hospitals, community hospitals, urgent care, group practice, home care, and congregate/communal settings (correctional health). But we are learning new information with every passing day– every passing minute, even, thanks to the 24hr news cycle, “citizen reporting”, social media and the like. What we “know” now indeed has the chance to be debunked tomorrow. The notion of “doing research” is losing meaning. There is far more value — although far less reliable calibration — in being WISE.

With all due respect, my physician colleagues and I “read the internet” very differently from how folks without similar background and training do. I am only posting the following because multiple people are asking for *my feedback* on whether or not to get tested, or how and when to get tested now that we are getting through the holidays. For this reason, I am not adding any specific references. Heaven knows the public has decided to seek their own sources, for better or for worse. If you can read this, you can read 1000 other articles or (God forbid) Facebook posts and the like. At the end of the day, you are still going to make your own choice.

Please only continue reading if you plan to respect my opinion. I have no crystal ball predicting who will read this, so I am clearly not here to prove ‘you’ wrong, whoever you might be. Just stating my own case. Thank you kindly in advance for all mutual respect shown.

There are fundamentally two reasons to get tested for COVID as an outpatient:

1. To minimize risk of passing along the infection

Anyone who believes he/she is at risk for being COVID(+) but is capable of strictly quarantining should simply proceed with quarantine if at all possible. Recommended duration of quarantine has varied greatly over the past 2 years, but at this time if someone is fully vaccinated/boosted and remains fully asymptomatic for 5 days after a suspected exposure, quarantine for that individual can be stopped at that point.

For someone whose vaccination status is not in keeping with the CDC/WHO recommendations, it is important to bear in mind that risk of transmissibility and/or severe disease is understood to be elevated. Outcomes in such regards are FAR FROM BLACK-AND-WHITE. But given the evidence we have access to thus far, it is advisable to quarantine more strictly if you are not fully vaccinated/boosted compared with those who are, in the range of 7-10 days.

If a negative swab of respiratory secretions can be obtained NO SOONER than 48hrs after the suspected exposure AND an individual remains asymptomatic, then quarantine can be stopped. It is still advisable to socially distance and stay masked for at least what would have been the duration of recommended quarantine, to help support public health and safety.

If there is an upcoming interpersonal encounter with a high-risk person that cannot be avoided within a 10-14 day time frame following a suspected exposure, a negative test result should be obtained before proceeding with the encounter.

If AT ANY TIME someone develops symptoms potentially suspicious for COVID and is capable of strictly quarantining and is not sick enough to need hospital admission, the advice is to simply proceed with quarantine until 48hrs of having no fever without medications to reduce fever (such as Tylenol or ibuprofen), AS LONG AS symptoms are resolved.

If someone has no fever but continues to have other respiratory symptoms, show courtesy and common sense by keeping your secretions as far away from other people as you can.

Testing requirements for specific situations like travel, access to events, elective medical procedures and so forth are SPECIFIC to the agency or entity. As a Primary Care Physician, I in no way can predict what the specific requirements are, whether in regard to timing of obtaining a test, selecting a type of test (e.g., rapid or PCR or… etc), producing a finalized test result, and so on and so forth. In order to help providing appropriate testing/results for an individual, I NEED TO READ THE POLICY that an individual is trying to adhere to. I am terribly sorry, but a verbal description of what is thought to be required is not enough for me to be helpful.

2. To justify treatment for a COVID infection

Outpatient medical therapy for an active COVID infection, thus far, remains highly difficult to access and involves jumping through multiple specific hoops. At my office, we have tried to assist some patients with obtaining an outpatient monoclonal antibody infusion but have been unsuccessful mostly due to limited supply and appointments. As a result, I am holding off on advising it for my patients until it seems more realistically available.

I feel it is riskier to send mildly/moderately ill patients to a closed infusion suite that contains confirmed COVID cases, not to mention requiring patients to leave their homes multiple times trying to obtain an approved confirmatory test, when compared with staying home and engaging optimal self-care (that is, resting and hydrating like it is your job, and if you are sick with COVID, this IS your job).

In other words, because treatment options for mild/moderate cases are extremely limited, essentially no change in approach would be advised regardless of whether a test is positive or negative. So if someone can quarantine and maintain the right level of supportive care (again: hydration and rest), there is no reason to test. COVID-POSITIVE STATUS SHOULD BE ASSUMED. Remain quarantined until essentially asymptomatic for 48hrs. Stay masked when in the presence of others thereafter. USE. COMMON. SENSE.

The primary indicator to seek hospital-level care would be respiratory distress. Other indicators would be high fevers (>103’F) or listlessness (prolonged deep sleep very difficult to arouse).

If AT ANY TIME someone contracts significant respiratory or infectious symptoms of any nature that seem severe enough to warrant a hospital admission, that person should proceed to the closest hospital Emergency Department without delay. Testing and any appropriate treatment would be rendered there.

Navigating the transition between a Pandemic and a Post-Pandemic World is tough on everyone. Let’s please all try to stay mindful of this.

We all wish the world were a better place. Many of us want to actively contribute to the world becoming a better place. If you have the bandwidth for that, wonderful! What you can offer is authentically needed.

But in sooooooo many cases, the most important contribution someone can make is to simply take care of him/herself without disproportionately draining the limited resources around. Please don’t pour out from an empty cup only to become the next vortex of need.

Stay well, seek wisdom, and be kind.

Part of Me

Still warming up to the vlogging, I sheepishly present my first original song on YouTube with absolutely awful sound quality. But I did it!

Since the audio turned out so poorly, in case you’re curious about lyrics, feel free to click the link below.

Otherwise, I’ll keep tweaking and bring this back around some other time. For now… peace!

Maiden Voyage with Vlogging – What is KNX?

I have been dreaming about doing something like this for a long time.

In fact, after I lost my brother in 2015, I had a host of ideas play out in my head regarding ways to publicly honor his memory. For someone like me, who more or less grew up on a stage, it’s hard for me not to do that. But then… I found myself consumed (again… see previous blog posts for reference) by the same thing that took him.

DEPRESSION. What is it, though, really? Well, on my prior blog posts I’ve endeavored to address it both clinically and personally. But my life’s purpose has been consumed with this at so many levels, that I’ll never be satisfied sharing what I’ve come to understand only through an essentially invisible blog.

I want to… I need to… touch the future in such a way that reduces the prevalence of depression in the generation of my children (known popularly as Gen Z), and perhaps in the generation that precedes them (Millenials). Unfortunately, for most members of my Generation (Gen X) and those who precede me (Boomers), it may already be too late. {=-< But if anyone in those brackets is touched by what I do, I am happy to count it a win.

At any rate, bear with me. I’m brand-spanking-new to this, but if I don’t start then it will never happen, and in my incessant mind, that isn’t an option. What I endeavor to do here is just as much part of my ongoing personal journey as I hope it to become part of yours. Or part of the journey for someone you care about who needs this.

I will be telling stories. Some will be about folks who have given permission or for whom details will be altered to protect their privacy. Some will be personal stories, but they will all be shared in the name of exploring ideas and truths — please don’t walk away with some false idea that you know everything about me based on what I decide to share. My personal business is going to stay personal, make no mistake.

I will delve deeply into theoretical concepts of neuroscience, social biology and even metaphysics without insisting on adherence or belief — these are just MY ideas waiting to be beta-tested and vetted. It wouldn’t surprise me at all to be completely debunked over the course of this explorative process, but for those who have not studied a scientific discipline, here is some news… truth cannot be found without giving air to possibilities that are eventually found erroneous. However, it is essential to remain open to probing and critique with every claim that is proposed, rather than stating unproven theories as if they are facts. I hope to contribute to this philosophical approach, which is desperately lacking in society today.

I will share music and poetry not because I expect acclaim, but because in my soul it begs to be shared, whether you like it or not (LOL)! And because the essence of depression and its variants simply can NOT be encompassed exclusively in scientific data-mining. In fact, the clearest descriptions of psychiatric illness are inarguably depicted in art.

In short, after churning and churning for years, I am reaching out to see what KNX.

If it works for you, I look forward to you joining me. If it doesn’t work for you, please feel more than welcome to just move on and find your own path. I won’t step on yours if you don’t step on mine, deal?