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.

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…

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/2009/02/in-rough-economy-give-patients-value.html

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

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…

“$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.

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.

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.