Healthcare System

Burnout Causes Problems

Just came across an article in the NY Times: Basically, its simply saying out loud something that most of us in healthcare see and know and do every day. MOST…. but not all.

Sequoia MD is built on now working this way. We are focused on not exploiting patients, or doctors, or nurses, but instead working in a way that is focused on excellent care, and should work for the long haul.

Progress Not Perfection

All day, I talk to patients about the idea of making progress, even if not arriving at perfection. Well, today in the office, we ran out of mailer bags, the bags we put medicine in when we ship it to patients.

We are all creatures of habit, and tend to continue with whatever we are doing. But I wondered, was there a better way to ship medications? Turns out, you can buy these mailers from 100% recycled plastic. Well, why not?

You might this is a small thing (it is!), you might think this is a silly thing to write about (and it is!), but I also think it’s an important reflection on making small changes, one at a time, to make the world a better place. So, from here on out, we will be using recycled plastic mailers. One small improvement, every day, adds up to big change over time. Its another way we practice what we preach.

New Faces

I am excited to announce that I am hiring a nurse practitioner to join me at Sequoia MD. Kristen brings energy, passion for great care, experience, and kindness to the team, and will be a wonderful addition to the office. 

Kristen’s hire strengthens the core pillars of what this practice is about— a long term relationship with your doctor, availability when you need it, a caring place to come when things are not going well, and a place to get your needs met. 

For the first few weeks she is in the office, she will be spending a lot of time spending time with me during appointments, and learning the ins- and outs- of how the office works. Since the practice has opened, I have been frustrated that I have no one available in the office on the days I am out. That will no longer be the case. 

Lastly, a word or reassurance. I know in a lot of offices, nurse practitioners are hired to make it more difficult to see the doctor. I want to be very explicit that her hire represents a great addition to the team taking care of you, not a gatekeeper to prevent you from seeing me. You can never have too many people on your side, and I hope that with time, she will be as helpful to you as I am.

As always, should you have any questions or concerns, please get in touch.

A Doctor in the Family

Being a doctor, family members often ask me medical questions. “Should I take this medicine at night or in the morning?” or “Is there anything else I can do for my arthritis?” While I don’t mind helping out with these kinds of things, really, it be nice if everyone had a doctor in the family— so something close to it.

That idea is a big part of what Sequoia MD specifically, an direct primary care more broadly, is all about. The entire premise of the practice is that is is built around a relationship. It used to be the norm that your doctor knew you, knew who you are. While that still exists some places now, it is, unfortunately, the exception. I want to bring it back.

I like the fact that sometimes, I see my patients at the park, or at the grocery store. I like the fact that my patients are a part of my community. I think its important to be there when things come up, they can call me— even if its just a small question, or something that you forgot to mention at an appointment.

Its not for everyone. Some people like big institutions. Some people prefer complex systems of care. Me? I prefer relationships with my patients, and I feel incredibly lucky that I get to have that, that I get to the be doctor in not just my own family, but in many families.

Open Enrollment

Its open enrollment season, and that means it may be time to re-evaluate your insurance coverage.

For those of you who purchase your own insurance (I recommend you have it!), as well as for those who get it through your employer, I put together a brief guide to the types of insurance that generally work best with Sequoia MD. I am not an insurance broker, and you need to make the decision that is the best fit for you and your family. However, below are some general guidelines on coverage that works best with the practice. If you have specific questions, please ask me, or your insurance person.

First, a quick note on how insurance works (apologies if you already know this). Every month, you (or your employer) pays a premium— the cost of your insurance. In exchange, your insurance pays for your medical services. While its a bit of simplification, the more premiums you pay, the less you expect to may out of pocket (the more your insurance pays).

Under most circumstances, lower premium/higher deductible plans work better with my practice. Because you have such good access to your doctor, there are a lot of things most people need insurance to cover that is already paid for through your membership.

Generally PPO plans are much easier to deal with than HMO plans. It is generally easier to get you in to see specialists, get tests covered, etc., than with HMO plans.

Coupled with an HSA (Health Savings Account), this is often a great way to save some money. 

Kaiser is challenging to mesh with Sequoia MD. Kaiser is a closed system, so of all the plans out there, it is most difficult to get Kaiser to pay for anything that I order or prescribe for you. You have to go through the Kaiser system if you want Kaiser to pay for it.

I understand health insurance can be confusing— finding the right plan, signing up, figuring out what your benefits are— it can be difficult to understand. For that reason, I have spoken with insurance brokers who understand the way my practice works. If you’d like some names, please get in touch.
Lastly, as a reminder, Sequoia MD is not insurance. If something comes up that is beyond what I can handle for you (car accident, surgery, etc), its important you have coverage for that. 

Cheaper Medications

So, incredibly cheap medications are a known benefit of being a part of Sequoia MD. Everyone knows that. So, what could be better than the medications you need, at a completely affordable price?

How about even an even cheaper price? I recently added another medication supplier, that has some even better deals than what I have been able to offer. It will not be for every medication, but for several medications, the cost will come down even more. I love it.

This will slowly filter through my stock. As I order new medications at (hopefully) lower prices, those cost savings will be passed along. Depending on the medication, this may take a little while to work through the inventory, and will not, unfortunately, apply to everything. I also ask for your patience in advance, as I anticipate having multiple suppliers may cause some small challenges with keeping things in stock.

Still, pretty cool though, right?

Its the individual...

This article hits the nail on the head around a lot of the current issues around chronic pain and addiction. It also is another example of another huge challenge in healthcare.

 One of the biggest challenges I see in medicine is the idea that "someone else" knows better. For any individual patient, that patient, and the doctor taking care of him or her, are going to make the best decision. It won't always be right, but it will certainly be a better decision than one make for 2.000 miles away.  Politicians, insurance company administrators, bureaucrats, "policy makers." and a long list of other people are going to know less about any given situation than the patient and the doctor. And yet, they often have as much (if not MORE) influence, in how an individual patient gets treated. 

This is true with managing pain. For a long time, doctors were very concerned about the dangers of prescribing opiates. Then a whole host of other people got involved, and basically told doctors they were not doing a good job, because we weren't controlling patients pain, not prescribing enough. Now, those very same people, are coming back and telling us we are not doing a good job because they are being prescribed too much. 

How about we let doctors work with patients to come up with the best treatment for that individual person? Complicated? No. Revolutionary? Maybe...

Its just a number (part 2)

The last post on language, diabetes, and blood sugar numbers applies not just to diabetes. It applies to most chronic health conditions. Take blood pressure management. Or cholesterol. Or any one of a number of things that are related to health.

We all want to be healthy, and we want indicators that are health is good. But the reality is that sometimes, we have work we need to do. However, instead of viewing a high blood pressure as a sign that "I am a bad person" try re-framing that to, "I'm glad I have that information, so that now I can take care of it." Instead of and elevated LDL (cholesterol) being something bad, view it as an opportunity to focus more on exercise; or on gratitude that we have found out that its high, so that we can address it with medications. 

When it comes to data related to your health, good and bad are in the eye of the beholder. Focus on the data, not the baggage that comes with it. 


Isaac Newton’s first law says something to the effect of, “An object in motion tends to remain in motion, and an object at rest tends to remain at rest, unless acted on by an outside force.” This is true in physics. This is true in managing a chronic health condition. This is true in life. The course we are on (or that we set ourselves on) tends to remain, unless we make an effort to change it.

Most people will stick with a current job (even if its lousy!) unless really compelled to change for some reason. People will stick with a broken system (ahem, healthcare), unless really compelled to change. People will continue exercising (if that’s the habit) or not exercising (if that’s the habit), until something spurs change. The interesting thing is, even when you recognize that something is not working, the perceived effort to change it is often greater than the perceived benefit. 

Change is hard. Always has been, always will be. The good news is that the effort to change is not required all the time. For example, when I see patients who have been using opiates or alcohol, they have been using consistently for quite some time. Why? Because change is hard, and inertia is working against them. Inertia is pulling in the direction of continuing to use. However, once people start treatment, inertia is working for them.  While things don’t always go smoothly, life is now moving in a better direction, and inertia will likely keep things moving in that better direction. 

So, its important to get  on a good path, to let inertia be your ally, not your enemy. If your inertia, your habit, is to buy healthy food at the grocery, odds are you will continue to do that. If you habit is take your insulin regularly, odds are you will continue to do that. 

Is inertia working for you, or against you? Is your daily routine bringing you happiness, or bringing you closer to your goals? 

The Chains of Habit Are Too Light To Be Felt Until They Are Too Heavy To Be Broken (attributed to many people, including Samuel Johnson, Benjamin Franklin, and Warren Buffett)

Eight Seventeen

I recently saw a patient in the office who sees a specialist. His specialist had started him on a new medication (that I also prescribe sometimes), but the patient hadn’t picked it up from the pharmacy. He said it cost too much. This man is not particularly well off, but does ok. So I asked him how much it cost. I was thinking maybe I could convince him to pay for it for a month, see if it worked, and then make a decision. 

“Eight seventeen” he replied. “Can you believe that?”

That didn’t seem too expensive to me, I  though he probably could afford it, but maybe it just wasn’t worth it to him. Still, I could try and find him a lower price, I like solving problems for my patients. I asked him to wait for a moment. Maybe I could shave a a few dollars off, and that would be the difference.  After a bit of looking, I found the medication and the price, and felt disappointment. 

“Sorry, I can’t beat that price. I can order it, but it would cost you about $12 or $13 to get it from me.” I was a bit bummed. I like to help if I can. Still, maybe I could convince him to try it for a month or two, see if it would help. 

“That’s fine,” he said, “could you order it?”

I looked at him. Why would he want to pay be an additional 5 bucks for the the same medication he could get more cheaply from the pharmacy? He told me cost was the problem, but was willing to pay more to buy it from me? 

“Sure, but why don’t you get it from the pharmacy?”

He looked at me. “Doc. I  told you, they wanted eight seventeen for it. I can’t afford that.”

I frowned. $8.17 is cheaper than $12, $8.17 is cheaper than $13, this doesn’t make any sense. I mean, I can order it, but why pay more? You just told me, cost is the issue. Then, slowly, it sunk through my skull. 

“DO YOU MEAN TO TELL ME THEY WERE TRYING TO CHARGE YOU MORE THAN $800 FOR THIS?” I felt like my head was exploding. I couldn’t believe it. The pharmacy was trying to charge him with insurance, $817. Eight seventeen. Eight hundred and seventeen dollars. 

He looked at me and shook his head, “Yeah doc, that’s what I told you. They said it was eight seventeen. There’s no way I can pay for it. Go ahead and get it for me, maybe this one will work.”

I want to be clear: I don’t stock every medication. I can’t get every medication for less. But boy is it fun when I can save my patient $805 on a single prescription.

Cheaper Labs

I am always looking for ways to lower healthcare costs for my patients, and so am excited to announce I just implemented new prices for labs that are even cheaper than before. How cheap? Very. Like, 10-80% cheaper than the already cheap prices you’ve become accustomed to. Now, I’m not saying this so that suddenly I start ordering lots of labs for you, but it is pretty nice to know that when you need them, you can get them with a minimum of fuss. And expense.

Healthcare can be expensive, but there are lots of ways to lower the cost of labs, medications, and other things that you and your family need. Lower cost, high quality healthcare-- that's what we are after. 

I’m working on a few more projects that hopefully will help with this over the next few months as well, so stay tuned. 

Adventures in Healthcare Land (Part II)

Have you ever gone to to pick up a medication at the pharmacy, and been told, “its not covered by your insurance.” Its annoying, right? Its also annoying as doctor when this happens: I pick what I think is the best medication for a patient, and then am told by an insurance company if this is ok, or not. You know what is especially annoying? When we are arguing over pennies. 

I recently got a fax from a pharmacy. I had prescribed a medication to a patient, and before the insurance company would agree to pay for it, they needed additional justification as to why this was the right medication. Keep in mind, this was a medication to decrease stomach acid in a patient who was having heartburn. But before I spent 20 minutes filling out paperwork and faxing it back, I decided to check my inventory, and see how much it would cost the patient to get the medication from me. The answer?


You read that right— about half the cost of your morning coffee. Oh, and that cost includes my mark-up. 

This is not an isolated incident, and is not the first time something like this has happened. I once had a patient wait 10 days to start a medication because the pharmacy had to get authorization for a medication for which I charge $1.53 per month (that is 5.1 pennies per day).

Now, I don’t think I can change the enormous healthcare system. I don’t think I will be able to change it even in California. But I do think I can change it for myself, and for my patients. Its a wonderful feeling; instead of getting angry about the absurdity of it, instead of trying to convince an insurance company to spend 5.1 pennies per day, instead of getting indignant because of the difficulties my patients are exposed to, build a solution that actually works.