Stressed Out System

Stressed Out System

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I saw a patient today and looked back at a previous note, which said the following: “stressed out due to insurance.” It didn’t surprise me, and I didn’t find it funny; I see a lot of this. Too much. This kind of thing could be written on a lot of patients’ charts. I suspect the percentage of patients who are “stressed out due to insurance” is fairly high.

My very next patient started was a gentleman who has fairly good insurance who I had not seen for a long time. He was not taking his medications as directed, and when asked why he had not come in recently he replied, “I can’t afford to see you, doc. You’re expensive.”

Expensive? A $20 copay is expensive? Yes, to people who are on multiple medications, seeing multiple doctors, struggling with work, and perhaps not managing their money well, $20 can be a barrier to care. I may complain that the patients have cable TV, smoke, or eat at Taco Bell, but adding a regular $20 charge to an already large medical bill of $100, $200/month, or more is more than some people can stomach. I see a lot of this too.

Finally, I saw a patient who told me about a prescription she had filled at one pharmacy for $6. She went to another pharmacy (for reasons of convenience) to get the medication filled, and the charge was $108. I could see the frustration and anger in her eyes. ”How do I know I am not getting the shaft on other medications?” she lamented. I told her that I see a lot of this.

Then I started considering how many doctors, nurses, and hospital administrators are “stressed out due to insurance,” and I laughed. I think the number of those not stressed out would be far easier to count. In this blog I have recounted the overall cost the insurance situation takes from my own practice, and my own psyche. I can’t do it justice in a single post, it takes a huge toll on those of us in it. The cost is high.

So what is the overall cost of a bad system? Sure, the system itself uses money poorly and dumps buckets of money on things that have no impact on the health of patients. Sure the system encourages doctors to not communicate, not spend time with patients, and to spend more time with the notes than with the patient. But what is the toll of this toll? What is the toll that simply having an insane system that demands huge sums of cash, yet does not give back a product worthy of that cost? What is the toll of people suspicious that they are being gouged at the pharmacy, hospital, or doctor’s office? What is the cost of having a healthcare workforce that goes home more consumed by frustration about the system than by the fact that people are sick and suffering?

Our system is very sick, and the fact that it is so sick makes me sick. It makes a lot of us sick.

I see a lot of that.

PREVIOUSLY by the same author on THCB:

“The Cost of Fear”
“Dear Mr. President”

ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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86 Comments on "Stressed Out System"


Guest
Lynn
Mar 10, 2010

Thanks for noting “insurance” is a valid stress issue. All too often physicians don’t ask and don’t note the possible causes of patients distress and noncompliance.
If only patients weren’t so passive about the issue. A letter to a Congressman or Senator making them aware that health care is a significant worry to them as a constituent/voter would go a long way to letting policy/decision makers know “status quo” is no longer an option.

Guest
Dennis
Mar 10, 2010

One critical thing you convey is the fact that you as a physician have to spend time on these problems. You’re not practicing medicine here: you and your patients are worrying about business transactions.
As a physician you can and should worry about nothing more than what is best for a particular patient in a particular circumstances. Where people are otherwise healthy and your diagnosis follows standards you know and regularly follow, the time you and your patients have to spend on this is time you cannot spend on the patients who truly need more care.
And the patients who spend time worrying about these matters (where they are legitimate matters — not the $100,000 a year lawyer complaining that the co-pay is $20) have to suffer through other worries when all they should be worrying about is are the steps you’ve instructed actually working to improve their health?
When are some people in this country going to wake up and realize this isn’t how medicine should work? When we treat so much of health care as a for-profit business, what you get is a lot of time spent on for-profit thinking. As a physician, I expect you to make a very good salary, but that should just come automatically from a being part of a good, respected practice. When you and your patients spend so much time having to navigate a marketplace looking for the appropriate medical care, it’s no surprise that the market overrules medicine so much.

Guest
Nate
Mar 10, 2010

Dennis you apparetnly still haven’t learned what the words for profit mean. Majority of hospitals are non profit, majority of insurance is sold by non profits, and the majority of care is paid for by government, which technically is non profit. Where exactly is this evil profit you keep blaming?
Wouldn’t any logical person conclude since the vast majority of the system is non profit that there are other issues? I know they are much harder for you to grasp and take more then 30 second sound bites to learn but you need to get started.

Guest
Dennis
Mar 10, 2010

Nate, I’m not going to waste time on your ad hominem attacks. If you want to rewrite what you wrote and direct your concerns at what I write and not who I am, I’ll pay attention.

Guest
Mar 10, 2010

Yes, kids, play nicely.
I would say that the “non profit” side of things (like BCBS) is a bit questionable. One would think that non profits would be significantly cheaper, as they have no shareholders to please with high margins. They seem, however, to follow the for-profits in their pricing. That is very suspicious to me – it says that they don’t have to be an efficiently run organization.
But the insurance industry and Pharma are not the root cause of the problems. The root cause is the set of laws that govern the administration of HC. A government takeover is not the only way for the government to act. It needs to focus on creating a climate for HC that encourages prevention over profit, that rewards efficiency and quality. Our system at present does nothing. Insurance and drug companies are a product of the system more than they are the cause.

Guest
archon41
Mar 10, 2010

Perhaps one of the resident insurance gurus would explain to us why insurers don’t simply agree with employers to pay forthwith all medical bills sent to them by employees, instead of insisting on written contracts to define and limit their obligations. I mean, that’s what Medicare does, right? Why not just commission someone to create a system where the provider has a direct connection to the check printer?

Guest
Anonymous
Mar 10, 2010

I was thinking the same thing, archon41. I wish I had a business where it cost a client $20 to get my services worth $100, and then I get paid another $80 when they show up, and then complain that my client had to pay anything at all.
Maybe that’s why a lot of doctors aren’t even trying to collect the $20 copay. That way, more clients show up and I still make $80.

Guest
Dennis
Mar 10, 2010

Rob,
You’ve described the system that exists in certain European countries. Everyone is covered, plans are private and regulated.
I just question what are the “set of laws that govern the administration of HC” that you refer to. Can you cite examples?

Guest
Mar 10, 2010

I am talking about the very basic level of laws. Why is the insurance situation the way it is? Much of it revolves around how Medicare is structured (such as an over-emphasis on charting, coding, and procedures). The insurance companies follow Medicare’s lead. The HMO act by Nixon was a big thing that pushed the situation toward more insurance co intervention – making them less insurance companies and more “disease management” companies. That, by the way, creates an immediate conflict of interest on their part as they are able to alter what they pay for based on their own interpretation. They are no longer risk-pools, they are money managers – deciding how it will get doled out. When they have a vested interest in not paying (to increase profits), they are difficult to trust with the money.

Guest
Dennis
Mar 10, 2010

I really don’t get how you can say “The insurance companies follow Medicare’s lead.” What would you contract your statement “over-emphasis on charting, coding, and procedures?” I agree with you that “When they have a vested interest in not paying (to increase profits), they are difficult to trust with the money,” but I don’t know what sort of alternative you are suggesting would work better. (Me? I prefer single payer — but that won’t happen).

Guest
archon41
Mar 10, 2010

Just imagine: In my simplicity, I had supposed that employers and individuals could not afford, or were unwilling to pay for, insurance policies which covered every medical contingency with no procedural fuss. It comes as a great revelation that they are guided, not by the express language of their policies, but by their understanding of what Medicare does. I had also supposed that some policies afforded broader coverage than Medicare or other policies. Otherwise, the term “Cadillac Plans” wouldn’t seem to make much sense. And what are we to make of all these Human Resources Managers who devote so much time trying to figure out the most cost-effective of competing insurance proposals?
But I will agree with Dr. Rob on one thing: making the government the sole paymaster for medical professionals would certainly tend to make some aspects of care less complicated.

Guest
Tom Leith
Mar 10, 2010

> Why not just commission someone to create a system
> where the provider has a direct connection to the
> check printer?
That’s the way Medicare worked from `64 to `84. Read Paul Starr’s book “The Social Transformation of American Medicine” to understand the history. You can get a used copy through abebooks.com for $10, shipping included. Less than a $20 copay! Such a deal!
> When [classical disease management HMOs] have a
> vested interest in not paying (to increase profits),
> they are difficult to trust with the money.
And when you have a vested interest in consuming “because I already paid in” and a doc has a vested interest in pandering to that, YOU are very difficult to trust with the [risk pool’s] money. And do not think for an instant that your single-payer will not try to do exactly what HMOs did — the motivation will be slightly (but only slightly) different, but the result at best will be the same.
There are conflicts of interest everywhere you look in this, as reading THCB for about a week will show you.
t

Guest
Mar 10, 2010

I am not a proponent for a single-payor system. I am simply against the chaos of our current system and I do think there are ways to simplify things.
Insurance companies audit charts more aggressively than M’care following M’care’s E/M guidelines. They use ICD coding like M’care and will reject claims or pay for them largely on the same procedures that M’care does. For example, if M’care pays for heart stenting, the insurance co’s will as well. But if M’care stops paying for that procedure, they insurers will jump off quickly. Many immunizations are not covered by private insurance until Medicare or Medicaid start paying.
Spend a week in my shoes (sandals, actually) and you will see it 1st hand. Reimbursement rates are different (thank goodness), but what is covered largely mirrors the public plans.

Guest
Mar 10, 2010

This is such a valuable post.
What if patients actually could know reliably and well before the moment of decision to go with a particular provider or pharmacy precisely what the service or drug would cost?
Sure, some insurance plans allow this most of the time, but….average plans have surprisingly more exceptions to this than anyone would guess expect the unfortunate.
My wife needed some physical therapy for her knee (which successfully recovered in time), and the provider made a reasonable estimate of the per visit insurance allowed amount (we have a deductible for this particular therapy).
So we thought we knew what the therapy would cost.
On that basis, we choose how many visits to make, against our medical savings, and under our careful total household budget. We paid the estimated out of pocket cost as we went along. We did about as much therapy as our budget allowed, since she still had pain.
Months(!) later, we received a bill, completely unexpected, from the physical therapist for the difference between their estimate and our actual allowed amount.
Unexpected, a little stressful. (Imagine an unexpected bill out of the blue for all of your available discretionary spending (fun stuff, restaurants, etc.) for one month.
Imagine our situation multiplied by millions and including a large portion of households with less savings or less ability to pay than we had.
That’s the reality.
If the computers owned by providers and insurers, which had all of this price information already, before the fact, were simply required by law to openly disclose accurate prices to patients….
That would be different.

Guest
archon41
Mar 10, 2010

This is a policy of insurance. Some things are covered and some things are not covered. These may or may not be the same things that are covered or not covered by Medicare. The things that are covered may or not be covered to the same extent as Medicare, and they may be subject to policy specific deductibles and copays. The insurer may or may not try to use Medicare reimbursement critera to define its obligations as to the amounts it offers in payment for covered services. Unless you are dealing with a contract of insurance that contains no limitations or conditions whatsoever (and I have never heard of such), the covered must be sorted from the uncovered. That requires a process. This would be so even if Medicare did not exist.