I’m Sorry

by Rob on March 10, 2009 · Comments

in American Medicine, Best Of, The Healthcare Problem

(+3 rating, 3 votes)

Loading ...

I am very worried about many of the things proposed by politicians for fixing our system. I think they aren’t listening to the opinions of people facing the crisis (doctors and patients). But I also strongly disagree with those who imply the system doesn’t need major change. It is a mess and will collapse without overhaul.

The following are not real patients, but are based on a number of patients seen recently. These things happen on a regular basis and are not only affecting care, they are hurting my relations with my patients. I am made the enemy and seen as uncaring about the financial woes of my patients.

Patient 1

“I can’t go to the emergency room! They will charge me $1000! I haven’t met my deductible!”

“Sir, your abdominal pain is severe enough that only they can do the testing needed and x-rays to make sure this isn’t something serious.”

“Can’t you just call me in something for the pain?”

“No I can’t. I am sorry about the cost, but my decisions have to be made based on medical facts, not the cost. I understand your worry, but I have to give you my best medical opinion.”

“I thought you doctors were supposed to care!” (Hangs up the phone)

2 weeks later

“You sent me to the ER and they told me it was just constipation! I paid $1000 for constipation! Why didn’t you just call something in?”

“At that point I didn’t know what was the problem. It could have been something very serious – there was no way for me to know over the phone. Constipation is a best-case scenario. At least it wasn’t one of the bad things it could have been.”

“That’s easy for you to say. You didn’t pay $1000 for constipation. I should bill you for the time I waited in the ER. You should have called something in.”

“I’m sorry. If I knew what your problem was in advance, then I would have. I was worried you had something life-threatening.”

Patient 2

“I am going to order some tests. Anyone with anemia like this without a good explanation is a worry to me. We need to order an upper endoscopy and colonoscopy.”

“My insurance will pay 100% for tests if they are screening. Can you make the colonoscopy a screening test?”

“Sir, you are under 50, so a screening test is not feasible. For me to code this as screening would probably not be paid for. Besides, it isn’t for screening.”

“My aunt had polyps. Doesn’t that increase my risk?”

“Not enough for justifying me putting it down as a screening test.”

“Why can’t you just call it a positive family history so that it will get paid for. The lady at the insurance company said that someone at my age would get it paid for if you did.”

“If I do that and am audited, it is my record that would be sited for insurance fraud. It’s my job on the line. I just can’t do that.”

“I just won’t get the test done, then.”

“But it could be cancer!”

“Too bad. I just can’t afford paying for the tests. The only way I can get them is if you put it as screening.”

“I’m Sorry, I can’t be dishonest in your records.”

Patient 3

“How come your prices have gone up?”

“Our prices haven’t gone up. Why do you ask?”

“Last visit cost me $150. I have never had to pay that much to see you.”

“It’s probably your deductible. We aren’t really allowed to increase our charge – it is based on what the insurance company agrees to pay us. We are kind of at their mercy.”

“$150 is a lot for a visit. You didn’t do anything. You just said I was OK.”

“You have diabetes and hypertension. You also had a head cold. I did some lab tests as well on that visit. I just give the best care I can. The charges aren’t at the top of my head when I am seeing you, but I can’t apologize for what we charge. Cardiologists can charge a lot more for doing much less.”

“I don’t have to see the cardiologist.”

“Yes. I’m trying to keep it that way.”

“I’m not sure I can afford $150 to see you.”

“I’m sorry.”

If you enjoyed this post, make sure you subscribe to my RSS feed!

An Open Letter to Consultants Dear Consultant: Thank you for agreeing to see my patients....
It’s not our Fault Dear Patients: I know you get frustrated with our office. ...
The Backstop I was going through patient charts this evening (from...
Decoding Coding Clever title…but I have yet to decode coding. I had...
The Uninsured There’s lots of discussion among politicians and “experts” on TV...

Related posts brought to you by Yet Another Related Posts Plugin.

Nominated For Best Medical Blog

Vote for Musings!

Frank Drackman

Sound's like y'all need to do some patient dumpin... I mean firings..or whatever they call it now a days... Thats what I like about Locums work,... are you really that hard up for patients??? I know its a hassle copyin the record...makin sure all the I's are Dotted and T's Crossed... Its what I like about the migrant workers, they don't complain (not that I can understand anyway) and pay Cash...

SeaSpray

Gee Rob..you are obviously doing your best and you have to do what you have to do.

The anemic patient was being foolish..possibly trying to manipulate you. I am not discounting their concern for financial end of it.. but a potential cancer diagnosis is certainly one thing to put off.

Can you as a physician, while maintaining your policies.. with empathy for their concerns, suggest that they may be able to set up a payment plan with various providers?

That is true.

I worry about what the new health plan will mean for me as a urology patient who wants to keep her urologist and has to have tests periodically..like renal scan next week.? I keep hearing how people will be on waiting lists and physicians more difficult to see.

Also, I have a PPO and as a patient who has had many office procedures and tests..expensive tests (next week is magIII w/lasix renal scan #6 in 3 years), 2 significant inpatient hospital stays, I don't remember how many SDS procedures, blah!... even with 10 -25% co-pay (25 nonppo) it ALL adds up and I have had to use payment plans.

I can also say from experience that sometimes if a patient is persistent..they can get the ins company to pay certain things.

*I* made a mistake once and did not precert for my rabies series visit at the ED. They were not going to pay. I broke the rules. I worked in registration and didn't think of it! But I was concerned about the rabies, etc. I pointed out that they would have approved it had I called. I told her if they didn't...I could possibly have died a very hideously painful death from rabies and they would have had a massive hospital bill from me being up in the ICU dying. She agreed and they paid it.

I know not all patients will be able to work things out with ins... but when you can..it does help.

It is a shame that docs look like the bad guys/gals when your just trying to do your job -help the patients and feed your family. They should be looking at THEIR insurance company.

SeaSpray

Meant to say "but a potential cancer diagnosis is certainly one thing NOT to put off."

Rob

I hold firm on these patients. Unfortunately I can't do much on the financial front for them. They are the ones who have to deal with the dilemma. I just feel bad for them. I try and be efficient with my care and only order what is needed. I have always practiced that way.

The unfortunate thing is that we are having these discussions at all. It just is a shame that money is standing between me and my patients, and between my patients and good care.

SeaSpray

Rob..I meant suggest that the hospital and other providers may be willing to set up a payment plan. Some patients probably don't know this. Or is that an awkward thing for a Doctor to suggest to a patient?

The other thing you could possibly say, while empathizing with their financial plight is "I understand how you feel, but what price do you put on your life?" I guess you can't say that either. But it is true. And their insurance will pay *something* which is better than nothing. Of course that is for the insured..what about the uninsured?

Then if they come back healthy... you again get chastised.

I do not think it is fair to put on you or any other doctor..unless the tests were CYA tests.

One night in the ER, we had a man who presented with chest pain and was to be admitted... but left AMA and against wife's pleas because he did not have insurance.

medrecgal

Yeah, it stinks, doesn't it? I felt really bad for the colonoscopy patient, but your hands are unfortunately tied by the "rules" of a system that needs serious overhaul in the way it operates. I can see the dilemma, too, for the patient with 2 chronics and a head cold; even with that little bit of information I know it could possibly come out to a level 4, which is potentially costly for a patient.

I don't know about our system from the docs' perspective, but even as just a coder I know it has serious problems; it is a money driven behemoth that doesn't do well by providers or by patients a lot of the time. (But when it does, it can be spectacular.) But how can we keep costs reasonable and still provide decent access to necessary services? Guess that's the big question and has been for a long time. I have yet to see a model of healthcare that would truly work well in our crazy culture...

And fudging the documentation to save a patient money strikes me as kindhearted but also unethical. Such are the dilemmas of the "system"...perhaps it's a good thing I didn't manage to get to med school; these kinds of problems would make me tear my hair out in frustration for everyone involved. You know something's really wrong when a doc has to debate between doing what's "right" by the insurance rules and doing what's right for the patient...

Rachel

It is obvious from your blog that you do care about your patients. I’m surprised that someone would think $150 is too expensive. I figure that it takes the receptionist’s time to schedule my appointment, to check me in when I arrive, and to pull my chart. The nurse weighs me, takes my blood pressure, takes a history, and makes notes in my chart. Then the doctor comes in and repeats the history (never have figured out why I have to go over that twice). If it’s a routine follow-up, he uses his expertise to determine whether or not everything is okay and decides what labs to order. If the visit is for an illness, then he has to figure out what’s wrong and come up with a treatment plan. When test results are sent to his office, the doctor looks at them and I get a phone call. All that extra stuff has to be noted in my chart, and then the chart has to go back on the shelf (no EMR yet, but even with EMR someone still has to look at the data and enter it into the computer). It’s not “just 20 minutes.” There’s a lot more that goes into it.

SeaSpray

That is all so true Rachel... but I am guessing the average patient doesn't put it all together. I do know it and would never deny my docs their fees. Yet (my household) we are in a season where 50.00 seems like a lot of money.

I am not saying that as far as doctor's billing because I expect things to be as they are and know their bills are appropriate.

I think some people may just be balking at the money because they don't have it in the current economy. Some are cheap. Some don't ever think about all that a doctor really does... and some probably don't care. Oh and some think ."Hey..he's a doctor..he's rolling in dough." and don't understand about overhead etc. But most..probably just have tight finances and really don't understand the whole process and ethics probably doesn't enter in to their equation either.

The Independent Urologist touched on this regarding coming into the office for lab results.

http://theindependenturologist.blogspot.com/200...

This must be so frustrating for docs and patients when insurance hinders the process for any reason.

prin

well, dr. rob, there's you and then there's this attitude which is what most poor people have to deal with...

http://crasspollination.blogspot.com/2009/03/me...

Rob

Prin:
We do what we can where we can. Leave those folks to themselves. I used to rant against that kind of thing. Now I just ignore it and set an alternate example. That's all we can do.

prin

i know i should have...i didn't...sometimes i just have to have a go at it, even if i know the continued ignorance that will follow me for days. :) thanks for the reminder of the higher road though :)

Rob

Truth be told, I pity people who carry such disdain for others. It seems that some never got out of the middle-school mindset of putting others down to make themselves feel big. Sad.

SeaSpray

Nurse K doesn't need me to defend her, but I just want to point out that she said "I wish silently in my head that welfare was compassionately kept for the truly needy---those who are disabled or chronically and severely mentally ill. When welfare is doled out to able-bodied people, everyone is hurt, especially those receiving it. "

She is expressing frustration..that I'll bet she doesn't express to them. I worked in registration, closely with a community emergency room and I understand the frustration and we got nothing close to the abuse that inner city hospitals get.

I personally don't say those things.

My own mother had/has MDCR/MDCD. She got it a while after she retired. She never once walked into an ED for anything. She was brought by ambulance a few times these latter years and 3 times last summer/fall but for true emergencies.

Fortunately for her... she had a compassionate internist agree to take her on as a patient even though his practice was full at the time and she had MDCD..which means they can't bill any balances after MDCD.

I was in a departmental meeting at the hospital one afternoon, when a co-worker with disdain brought up MDCD patients and basically had the attitude that they were lowlifes.

With the Director of finance for all facilities sitting there...i quietly stated that my mother has MDCD. You could've heard a pin drop. She looked embarrassed and looked down.

I felt embarrassed saying it..but I spoke up.. because I KNOW...there are many people who have or do work hard.. but for what ever reason...they couldn't make ends meet. I always feel bad when I hear the mDCD masses generalized and lumped into one... when there are good people too. Young, old and in between. Thank God for the help. GOOD people. And I have seen where they get the help they need, rise above their difficult circumstances, no longer need assistance and have become productive and give back to society.

I know we all know this.

But I think it is the generational MDCD abusers that are hurting everyone else...including themselves..but they don't realize it or care.

Or the illegals that get everything free.

I don't want to see anyone suffer... but if I saw some of what she sees all the time... it would be discouraging and frustrating and I am sure maddening. I don't know nurse K at all... but I have a feeling...all that negative energy you see expressing her disdain for milking the system... I think she just as passionately throws herself into facilitating healing and emotional support of the truly ill. Just a hunch. (I've seen it at work)

prin

when i went over there the second time i noticed the lorazepam banner and wondered if she was withdrawing from it. i could then understand a person with a "jones" writing something like that...maybe...

Nurse K

You people seem to be more judgmental than me!

If you're really getting your panties in a wad, you should know that I spent a solid 3 minutes talking to that woman about the importance of having a community doctor and gave her my medical resources packet for low-income and uninsured people which does many things, including listing area doctors that accept Medicaid---not just listing them, telling how to get there, the hours, the conditions treated, etc. Who designed that packet for low income people? ME. I'm JUST a staff nurse and had to do no such thing. There is a strong theme of empowerment and every section tells you exactly what to do. The dental section says, "It is very hard to find a sliding-fee dentist with an open appointment, so don't be frustrated if you have to make many calls!" The medication section talks about the $4 prescription plans and says, "If you can't afford your medications, ask your doctor if you can be switched to one that costs less!" Seems like 'no duhr', but many people simply stop taking medications or give up right away in situations like this.

Also, maybe you'll be happy to know that said packet has allowed me to speak to managers in my hospital and managers and leaders in my hospital system as a whole.

I work with these people every day, and it's not a big secret that welfare users have greater than 85 emergency department visits for every 100 users PER YEAR, most of it for non-emergencies that can be seen at the clinic. The stuff I wrote about on my blog is very prevalent, that attitude of learned helplessness.

After my education moment, she was psyched to get a community doctor and asked me to make her an appointment. Just another example of learned helplessness. I told her it was as easy as picking up the phone and it was her job to find an appointment that fit her schedule. She looked at me like I just told her to take a bath in excrement, but she said she'd make the appointment herself. It's hard to break the entitlement mentality and learned helplessness that welfare instills in people since birth, but I'm trying to do it with 2-3 minutes of education and my little packet. The 'phone' example is one example of something that I see every day. I can call 10 of my girlfriends in the lobby, but ask me to make an appointment, and somehow I can't do that because I've always just gone to the ER when I need something.

So, you can say Nurse K's a bitch, but Nurse K is trying to change these things that our welfare system has instilled in these people from a very young age by helping people make appropriate health care decisions that help our bottom line (48 million of charity care last year alone) as well as the patient's well-being. Being outspoken goes a long way.

So bite me.

Nurse K

“$150 is a lot for a visit. You didn’t do anything. You just said I was OK.”

BTW, clinics I refer to have starting fees of $20 for the uninsured or those with low income and high deductible health plans. Maybe your patient should come talk to me; I'll tell her where to get more affordable care. I'll also access a database of pharmacy prices to tell her exactly where the cheapest script are for her. Then I'll glance at her med list as a service to her and, from memory, tell her which meds have a reasonably similar $4 equivalent that she can ask for. There are many clinics that are starting to charge the uninsured the same as if the patient had Medicaid and getting charity donations and government grants to make up the difference.

Rob

One of the docs in our practice left to form a clinic for indigent patients. For those who can't afford care, we send them there. Most of the patients in my suburban practice pay far more than $150 for Cable TV, dining out, or other forms of entertainment. They may not like to pay it, but it is certainly reasonable for the service we give (since we are not subsidized like the indigent practices).

Your gripe is people misusing the system. My gripe is people complaining about my charges when they spend way more than that on suburban frivolities. They think nothing about going under the car payment for a Lexus (or even Toyota), but feel like I should somehow be willing to charge far less.

I don't apologize.

JP

Nurse K, have you ever been uninsured and sick? Or uninsured for a long period of time? Because I have, and it stinks. In our depressed economy its easy to eat up 12 hours on the phone and 6 hours of driving and waiting at clinics, community medical centers and urgent care facilities only to get turned down because they are at capacity. If you have not previously had access to good, consistent medical care and are jumping in blind, it can be very difficult to learn how to navigate the complexities and loopholes of the health care system. You said that sometimes these lazy medicaid patients whom you so distain would rather "go without" then make a few phone calls, but sometimes, after the phone calls don't pan out and the leads you get from them dry up, it feels as though the only option left is to give up, because the system is too insurmountably difficult for someone without experience in it, and with limited financial resources, to handle.

And who are you to judge from a short encounter who is and isn't fit for financial assistance? You claim that the money is going to the "able bodied" but you don't actually know what underlying health problems that someone might have just from looking at them. Just from looking at me one would have no idea that I have asthma, and that sometimes a brief jog to the bus stop when running late is enough to send me into a serious asthma attack. Because I look healthy. I'm young, and try to stay athletic as a preventative measure. Though I now have insurance through a state program for low income individuals and familes (the state purchases policies in bulk and gives them to those who qualify for a very low monthly payment), I spent months on a waiting list. When I was at my poorest, and uninsured, I spent time worrying about whether or not I'd be able to buy food, pay rent, or stay in school should I get injured or sick. I have badly sprained both my ankles (four years apart) and been unable to afford a doctors visit or ER visit either time. Also, poor people, even ones that aren't seriously mentally ill (does that mean no assistance/care for the non-seriously mentally ill? So the schitzophrenic gets care but the person with panic attacks doesn't?) or obviously physically sick deserve access to care that they can afford, as a way to stay healthy and continue to be productive. If that care is cobbled together through clinic and ER visits because they can't afford anything else, then thats how its going to happen. This doesn't mean that these people are lazy, bad or less worthy, it means that they're using whatever resources are available to them to gain access to some level of care. While it does strike me as ridiculous that Dr. Rob's wealthy suburban patients feel comfortable spending a couple hundred dollars a month on car payments, but feel weird spending $150 at the doctor (though, it does feel frustrating to spend money at the Dr's office and leave w/o answers, particularly if you don't have insurance helping you cover the costs), such individuals are increasingly atypical in an environment where thousands of people a month are losing their jobs, their insurance and their means of paying for any healthcare not covered by their insurance.

IMO the solution to this would be a single-payer healthcare system. From everything I've read this system would lower the cost for both Doctors and Patients (though I could be wrong on the lowering-the-cost-for-Dr's side of things) while providing universal access to people of all income levels. Because health care shouldn't just be for those with insurance or those who are wealthy enough to pay, and poor people shouldn't have to pass a "sickness test" in order to be deemed worthy of getting aid to see a doctor (as Nurse K suggests). Access to health care is up there with food, shelter, and education as something that all humans should have the right to have access to at a price they can afford.

Ken O

I'd been trying to stay out of this one, but I have to say that I'm in more or less complete agreement with JP! Particularly "Access to health care is up there with food, shelter, and education as something that all humans should have the right to have access to at a price they can afford."

Nurse K

Nurse K, have you ever been uninsured and sick? Or uninsured for a long period of time?

Yep, I have. I went two winters without central heat (where it gets down to 10 and 20 below) and several months without adequate sanitation. Using your oven to heat your trailer is not a good idea, btw.

However, I never asked anyone for anything, I just kept working and going to school and barely staying afloat. I have one serious chronic illness, and used my hard-earned money from my two jobs to pay for meds and stuff out of pocket. I probably had a lower standard of living for those 2 years than most of my patients ever had. It was even to the point of my neighbor who hunted deer coming over to give me extra meat so I had meat to eat.

I'm guessing they at least have a functioning toilet and heat. I think I have plenty of credibility to comment on layzeeness and apathy because I had neither and got out of poverty just fine and am better for it. This woman, despite having no obligations, couldn't even call to make her own appointment---she expected someone to do that for her. It's representative of the whole problem with welfare---entitlement, apathy.

As for "access to health care", note how she went to the ER with a canker sore. Seems her access to health care was just fine. If she didn't have any access to health care for this problem, she could have gone to the pharmacy or taken tylenol for the problem like everyone else or, gasp, SUFFERED with her 10/10 lip pain until it went away. I suppose you think everyone on welfare should have access to the highest and most expensive level of care for a common problem that no reasonable person would seek any health care for, but I don't. Again, with the apathy, she hadn't even bothered to try to go to a clinic even though clinics that accept medicaideurs are everywhere.

We forget that people get this way---apathetic and unable to think for oneself--- because welfare is so "accessible". There is a certain % of the population that will keep using whatever is given to them rather than doing things on their own until such opportunity is taken away.

If you want to see how welfare affects people, come to the ER. You'll agree with me after very few shifts.

Terri

Back to the topic of need to reform the health care system...the "simple" solution frequently seems to be related to dumping more money into the system.
It is critical for every single member of the health care system to acknowledge that there are mutliple problems within the system that need to be identified and fixed. Dumping more money into the abyss is not the solution.
My daughter, who has chronic medical problems, was recently hospitalized. It was supposed to be a 72 hr admission, but took 10 days. She had previous reactions (red man's) to vancomycin, so she was hospitalized to start the drug and find the right combo of tylenol and benadryl to control the reaction, and also get drug levels to ensure the drug is effective but not too toxic to her kidneys.
Every single day there was a problem...drug not delivered on time (setting up a reaction b/c too far away from dose of benadryl), unable to obtain an accurate trough level (usually hours off schedule, sometimes due to centralized phlebotomy showing up whenever, sometimes because the med wasn't delivered on time), and changes made to premedication doses (b/c my daughter was not sure if reactions were due to med given late vs inadequate premedication) and vancomycin dosing (is that level really too high, or simply b/c level wasn't drawn at the right time and/or because the doses were so off schedule).
So the hospital stay will end up costing over $50,000 instead of what should have cost under $10,000.
Not to mention the suffering my daughter endured that doesn't even get mentioned...multiple unnecessary sticks and reactions, and 7 extra days of her life spent trapped in a hospital room. Past hospitalizations would have included nosocomial infection, but we've learned the hard way that we have to be major pain in the asses and request gowns/gloves and own equipment (BP cuff, pulse ox, stethoscope), much to the annoyance of some of the staff. Sorry to those who do wash their hands and clean equipment between pts; if you could get all of your co-workers to do the same, we wouldn't have these special requests. And believe it or not, I have no doubt these extra requests save money in the long run. C. diff would have extended the stay and treatment regimen.

Rob

Yes, Terri, your story demonstrates that "simply socializing" is not the main solution. If a system stinks, it doesn't matter who is paying for it, the system has to change.

I have long felt that managing medical information is more important than cost - as the incredibly bad communication results in an incredible amount of cost. Build a system that actually knows what it is doing and does what it should, and you'd save a whole lot. Your daughter sadly paid the price for the non-system we have.

I don't know what I think about a single payer system. It just seems we change from greedy people running healthcare to bureaucrats doing it. Government and politicians can help us come to a solution, but they are not themselves the solution.