Happy 2023! A Covid and Practice Update for my patients (and anyone else interested)

From me and Atembis LLC .

???????????Hello, everyone! Welcome to 2023. So sorry it’s been so long since I’ve written one of these healthcare updates. I’ve been watching the trends, the research, and my own observations of Covid-19 illness and vaccinations. I can’t say that Covid behaved how I hoped, but I can say that it behaved somewhat as I expected. This is based on how I expected people to behave as well. I continue to say that the politicization of healthcare was very, very unfortunate, and resulted in unnecessary death and illness. https://www.theguardian.com/us-news/ng-interactive/2021/jan/18/us-covid-19-coronavirus-death-toll-visual-guide If we could just let science be science, we could have done better.

???????????So, Covid.

???????????As I’ve said before, the contention that Coronavirus is just a cold virus is somewhat true—the illness which produced what we now know as Covid-19 is a familiar virus, related to previous cold viruses. https://www.lung.org/lung-health-diseases/lung-disease-lookup/facts-about-the-common-cold But saying it’s just another cold illness is likely saying a Formula 1 race car is just another car. We now know that the earliest manifestations of this illness had a high overall mortality rate, especially in our seniors. https://link.springer.com/article/10.1007/s15010-022-01787-x The highest death rates came in people who were elderly, obese, and/or diabetic. This led to significant healthcare disparities and access to care. This is why I fought so hard against the provision of Covid vaccines only at State supersites. https://khn.org/news/article/feeling-left-out-private-practice-doctors-patients-wonder-when-its-their-turn-for-vaccine/ People without computers, cars, or the ability to get away from work for several hours found themselves unable to get this crucial vaccine. I finally got the governor’s office to relent and allow community physicians to distribute the vaccine as well. https://www.fox10phoenix.com/news/chandler-doctor-providing-covid-19-vaccine-to-his-patients-in-office

???????????Since then, we’ve gone through several iterations of the Covid illness. We now are in the throes of Omicron virus B1.1.529. This is a subvariant of Omicron (there are five separate “linages” and descendant lineages). https://www.who.int/activities/tracking-SARS-CoV-2-variants . What I’ve observed, and what I’m sure the future research will reveal, is that these subsequent manifestations of Covid are probably going to be more contagious and less deadly. Why do I say that?

???????????A perfect virus is one that is very contagious, has a long prodromal period (a period where you don’t have symptoms but are contagious to others), makes you sick and very contagious during the duration of illness, and does not end in your death. Death of the host is not optimal for any virus. And so, as viruses mutate, they typically mutate to a less deadly form. However, you need to add to this picture the very unfortunate element of population infectious disease statistics is that deadly viruses kill off the most susceptible hosts first. Eventually, the number of death-susceptible hosts goes down to where mortality rate is perceived to drop, but in reality it’s simply that those people likely to die from the virus have already died.

???????????That was that race against time we had in the beginning of this pandemic. We knew we had to develop a vaccine, develop it quickly, protect the population while we developed it, and then get that vaccine to our most susceptible hosts as well as those most likely to contract and transmit the illness first. That’s why healthcare workers, elderly, and people with comorbid illness got the vaccine first. What complicated all of this, though, was the politics. Many elderly people chose not to get the vaccine. What I’ve personally seen, very sadly, is that many of these people ended up severely ill or died. Again, I insist, unnecessarily.

???????????China is dealing with the polar opposite issue. They utilized a “zero Covid” policy, wherein if Covid was detected in a community, they shut down the entire community and sometimes city. They immunized what I imagine was a large portion of their population utilizing a vaccine focused on early virus subtypes, but not the newer subtypes. And when they dropped their stringent policies, we are now seeing huge numbers of people contracting Covid. https://covid19.who.int/region/wpro/country/cn My biggest concern about this is that the more people are infected, the more the virus has chances to mutate. https://journals.asm.org/doi/10.1128/JVI.01031-17 I am concerned that this will lead, once again, to a new variant resistant to current vaccine and infection derived immunity, and that we’ll once again be dealing with waves of illness. And Covid doesn’t seem to have a season. There doesn’t appear to be any commonalities. https://www.medpagetoday.com/special-reports/exclusives/98902 You will just have to watch for current illness rates for now.

???????????So that drive for social distancing, masking, restricting contact, controlling business flows, were all an attempt to buy time.

???????????Now, here we are three years later. Many of you have been asking me what’s the next move—when do we get vaccinated, do we need to mask, etc. So what I write here is based on 1. Science, 2. Observation (which is an essential element of science), 3. Calculation, and 4. Inference. ?I hope it makes sense to you.

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Vaccines

???????????If you have not been vaccinated by now, you might ask if it’s too late. It’s never too late. If you have not been vaccinated and you’ve never had Covid, I would be very surprised. You may want to have an antibody study to determine if you’ve been exposed. https://www.nytimes.com/2022/12/14/briefing/never-covid.html If your antibodies are negative, you should have the Covid vaccine, but make sure to use the bivalent. I know it’s not approved for a primary series—I would still strongly suggest you have a bivalent series as your primary series because the old vaccine is not going to be effective. We at Atembis are willing to give you the bivalent vaccine as your primary series.

???????????If you’ve been vaccinated previously but have not had Covid since June and have not had the bivalent vaccine, I would suggest now would be the time. If you had Covid since June, you should be vaccinated with the bivalent vaccine six months after contracting the illness. This is to boost your immunity against our current variants.

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Masks

???????????Yes, they still work. Yes, you want to try to use an N95 if you are going to be in an area where people with Covid might be. And trust me, it’s out there. I would guess that right now if you are in a room with 100 people, probably one of them has Covid. It may be very mild or completely asymptomatic. So if you are susceptible or at-risk (senior, diabetes, asthma, COPD, on chemotherapy, immunosuppressed, obese, or live with family members at risk), you should wear an N95 mask in an enclosed room. My favorite N95 masks are the 3M Aura masks. https://a.co/0L4p3qv The other surgical masks are really mostly effective if you are concerned about transmitting Covid to others, and you don’t know your current status. Testing often is very helpful. Speaking of…

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Testing

???????????You really should have some spare antigen tests in your home. Costco sells them very cheap. https://www.costco.com/flowflex-at-home-covid-test-kit%2c-5-test-pack.product.100825502.html I think they are best at identifying if you are in a contagious state. They may be negative early in an illness though, so if you’re concerned that you may have Covid and your home test is negative, a better test is the PCR test. Testing is also useful near the end of a Covid illness to see if you’re still contagious and safe to return to normal activity. If it’s been seven days and you’re testing negative, it’s probably safe to be around others, especially if you’re asymptomatic for 48 hours. If it’s seven days and you’re still positive, wait another 3 days before return to normal activity. At Day 10, unless you’re immunocompromised, it’s probably safe to return to activity, with or without testing. If you’re ever unsure, please call to schedule with us and we’ll walk you through it all.

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Monoclonal antibodies

???????????This treatment is like sending a heat seeking missile into a rocket. The treatment attached itself to a specific site on a virus, allowing our bodies to neutralize the virus quickly. Unfortunately, as viruses mutated, so did those attachment sites. Currently, we have no monoclonal antibody therapy available that works well. https://www.fda.gov/drugs/drug-safety-and-availability/fda-updates-bebtelovimab Hopefully, they’ll be able to develop a new treatment that is more resistant to mutation.

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Paxlovid

???????????This treatment works by inhibiting replication of the virus. It unfortunately has many interactions with other medications, so even when we would like to use it in people with multiple comorbidities, we sometimes cannot because it interacts with another medication that person is taking. There also is a “rebound” effect in some individuals which, when the medication is completed, allows the virus to once again replicate quickly and the person is sick again (though not ask sick as before). https://emergency.cdc.gov/han/2022/pdf/CDC_HAN_467.pdf This increases the duration of illness, but we’ve observed reduces the mortality rate, which is the most important endpoint benefit.

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Moving forward

???????????Vaccination provides you very good protection. https://www.cdc.gov/mmwr/volumes/71/wr/mm715152e1.htm Surviving a Covid illness gives you excellent protection. https://www.nejm.org/doi/10.1056/NEJMc2200133 Masks provide you situational protection. https://pubmed.ncbi.nlm.nih.gov/35218279/ Being outside provides you ventilatory protection. And being careful just makes good sense. In 1986, I got in my 1978 Toyota Corolla (my first vehicle), put on my seatbelt, checked my mirrors, started my car and drove off. Now I get in my car, still attach my seatbelt as always, but I don’t think about my airbags or braking sensors or antilock brakes, or traction control, or all-wheel drive or seat belt pretensioners, or crumple zones or reinforced A-pillars. However, all of those things were created by science, needs-perceived by observation of deadly car crashes, designed, tested, redesigned, manufactured, improved, and now the mortality rate from motor vehicle accidents is lower than ever. Think of science in this way, and it’ll make sense. I don’t use the same kind of phone as I did when I was 8. That rented rotary phone would take me forever to send out a text. ?

???????????We will get there with Covid, just as we did with Polio, Measles, Pneumonia, and even Cervical Cancer. You just need to be smart, be protective of yourself and your loved ones, and listen carefully to the arguments made by both sides. Do what makes logical sense. And even if you and I disagree, I appreciate that you listened.

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So a few practice updates

???????????Now that we’re in a new year, I wanted to send out a few practice updates. We will be calling many of you on Medicare Advantage programs to schedule your Wellness Exams. These Medicare Advantage programs want us to get these Wellness visits done within the first Quarter if we can, second Quarter at the latest. We will also be working on getting Medicare Part B patients scheduled, as this is also part of the program we’re working with. If you know of people wanting to join our practice as new patients, we are currently accepting new patients. These may be booked out to February, however, given current patient loads.

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New billing

???????????We will be using a new billing software starting in February. You will find that we are able to send an electronic bill as soon as your claim is completely processed. We ask that you pay your bill as soon as you can. We have had a significant number of difficulties in 2022 in collecting balances, which is why we’re changing software. So our statements may look different. If you ever have a question about whether an email or text is a legitimate bill from us, please call us.

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Major changes in 2024

???????????Yes, we’re looking that far ahead.

???????????Medicare Advantage and other insurance programs have gotten way out of hand. For example, UnitedHealthcare projects cash flow between $23 billion and $24 billion for 2022. https://www.fiercehealthcare.com/payer/unitedhealth-group-expects-at-least-317b-revenue-for-2022 That’s a “B” in that billion. And how do they make that profit? They leverage the Medicare Advantage program (Optum), their control of a Pharmacy Benefits Manager (OptumRx), Mail order pharmacy (same), billing companies, etc. But on top of that, they deny a lot of care, they force an onerous and unnecessary prior authorization system, and they make it hard as well as expensive (through copays, deductibles, coinsurances, and denied care) for you to access healthcare.

???????????This must stop.

???????????And the only way we can get it to stop is to stop accepting it as a viable means of delivering healthcare. It is not payers that provide you with your care—it’s the doctors, nurses, hospitals, etc. So why do stockholders get to profit from the care you didn’t receive? It’s not right.

???????????We are strongly considering quitting some of our healthcare payers by the end of 2023. We would likely continue to do business with the non-profit payers (Blue Cross Blue Shield is one of them). We will probably be moving to a membership model (almost like your Netflix subscription) to provide focused, low volume, high availability primary care. 24 hour access. Telehealth when you want, where you want. Hour long appointments. No lab fees. Low cost meds. We hope to have this all in place by the beginning of 2024 as a separate division from our traditional care, which would continue accepting health insurance companies focused on improved healthcare for people, not profits.

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Thanks again for trusting us with your healthcare.