I saw the note on the patient’s chart before I opened the door: “patient is upset that he had to come in.”

I opened the door and was greeted by a gentleman with his arms crossed tightly across his chest and a stern expression.  I barely recognized him, having only seen him a handful of times over the past few years.  Scrawled on the patient history sheet  in the space for the reason for his visits were the words: “Because I was forced to come in.”

By stomach churned.  I opened his chart and looked at his problem list, which included high blood pressure and high cholesterol – both treated with medications.  He was last in my office in November…of 2008.  I blinked, looked up at his scowling face, and frowned back.  ”You haven’t been in the office for over eighteen months.  It was really time for you to come in,” I said, trying to remain calm as I spoke.

He sat for a moment, then responded with very little emotion: “I am doing fine.  You could have just called in an order for labs and called in my prescriptions.  I don’t know why I had to be seen.”

“You have hypertension and high cholesterol.  These are serious medical problems, and if I am going to put my name on a prescription for you, I have to make sure everything is OK,” I responded, trying to hide my growing anger.  ”I am not a vending machine that you can call to get drugs.”

“I’ll come in if I am sick, but I am not sick right now.”

“My job is to make sure you don’t get sick in the first place!” I said, my volume rising slightly.  ”I don’t bring you in because I need the business; I’ve got plenty of patients to fill my schedule.  These medications are not risk-free.  Besides, how do I know if your blood pressure is OK?”

“I check my own blood pressure at home and it has been good.  I can’t afford to come in to the doctor so much.  I have a high-deductible plan.  I had a stress test and a colonoscopy last year, and that’s enough spending for me,” he responded, his pitch and volume rising with mine.

“I have to say that I find this personally insulting,”  I threw back.  ”You don’t think I am worth paying to see.  You just want me to give you your medications, take the risk of adverse reactions, and basically work for free?”

“That’s not what I said!”

“It is exactly what you said!” I said, not hiding my frustration.  ”You want me to prescribe a medication, trust you for your blood pressure, interpret the lab results, and take the legal risk for your prescriptions and not get paid a dime for it!  You are asking me to give you bad care because you don’t think I am worth paying.  I don’t do that. I won’t give you bad care.  If you wan’t bad care, feel free to find a doctor who will give it to you; if you are going to come to this office I will make you come in on a regular basis.  If you don’t think I am worth it, then I am sorry.”

He sat quietly for a moment, and I took a deep breath.  ”Don’t you have a health savings account?” I asked, trying to calm my voice again.  ”Most people with high-deductible plans have HSA’s.”

“Yes, we have an HSA, but we are trying to hold on to that money.”

An HSA is an insurance plan!” I said, not hiding my incredulity. This is what you’ve been saving that money for!  I want to keep you out of the hospital, keep you from the emergency room, and keep you from spending all your money for a hospital stay.  One overnight stay in the hospital will cost you more than 100 visits to my office.”

He again sat quietly for a moment, and I directed him up on the exam table.  We talked about his medications and potential side effects.  I pointed out that there are cheaper alternatives for his blood pressure pill that have fewer side effects.  I discussed cardiac screening tests and explained the pros and cons of prostate cancer screening.

I changed his prescription to something cheap enough to recoup the cost of my visit in two months.  As the visit went on, his eye contact grew less and less.  My point was made.  I was giving him something the Internet or a “doc hotline” couldn’t give; I saved him money, educated him, and improved his life.

When I had finished with the visit, I handed him the clipboard.  ”I’ll see you in six months.”

He didn’t respond, but I could see that he got far more out of the visit than he expected.  I am the one doctor out there whose main goal is to keep him away from the hospital and away from having expensive tests.  I often tell my patients that my goal is to get all of my patients very old and to see them as infrequently as possible.

But I am not a vending machine for prescriptions.  I won’t work for free.  I won’t take risk without expecting to be paid for it.

I hope he comes back.

I hope he realizes I am worth it.

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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67 Responses for “Worth It”

  1. rbar says:

    Nate,
    I am not that far away from your position as you may think.
    First of all, your rhethorical question: “(now and 40 years ago) You still go to the doctor for an office visit, you still pickup your Rx at the pharmacy. What exactly has changed.”
    1st, you could as well state: what has changed since the stone age? People still eat, talk, cohabitate, and die.
    2nd, look at bills for outpatient care in 1970 and 2010. If I need to elaborate on that, let me know (no, I will not follow your typical communication pattern of insulting people who have a different opinion).
    There is no doubt IMHO that there is overutilization because “3rd party will pay”, and we have to change sthg about that. A generic drug plan, for instance, makes sense, forces both provider and patient to look for affordable alternatives (and will also improve the quality of pharma research – you cannot sell every new shit). However, copays/deductibles for routine visits are just not a good idea. The not so smart patients will start to be stingy on stuff that does not make them feel unwell in the short run (e.g. antihypertensives, antidiabetics) … well, let these unresponsible people get sick might be the libertarian response. But while this ideology might be acceptable for other decisions (financial and otherwise), it does not work in the medical field because: the majority feels that it is the right thing to treat the individual collapsing on the street with a heart attack, even if he/she made the wrong health care choices. Therefore, it is, in my opinion, not just question of self pay (BTW I never mentioned any specific priciple like high deductible plans in particular), but a question of creating a fair, clear and transparent system of incentives (negative and positive) that encourages people stay healthy . And health care is, for society as a whole, only a small, but very costly part of staying healthy.

  2. Barry Carol says:

    Margalit, Nate and rbar,
    I have a middle of the road view of this issue of the extent to which routine primary care should be largely covered by health insurance. With respect to the upper half of the income distribution, I think people should be prepared to self-pay either out-of-pocket or from an HSA account. While I have no doubt that people who ensure that they get the appropriate preventive tests and evaluations will live longer, healthier lives (a good thing for them certainly), it probably doesn’t save money for the healthcare system on a lifetime cost basis. A recent study out of the Netherlands, for example, found that smokers die on average seven years sooner than non-smokers and incur lower lifetime medical costs. I don’t want to be the nanny for everyone else and I don’t want to require that minimum insurance coverage must include comprehensive care with a low deductible and low or no co-payments. If people who can afford to pay for primary care choose not to access it and would rather spend their money on cable TV, if they die sooner than necessary, that’s their problem. If I have to help pay for their heart surgery or stroke recovery because they didn’t take their blood pressure medication, I’m probably avoiding the cost of their nursing home care much later in life if they wind up suffering from dementia or Alzheimer’s. As for employer wellness programs, they can and do save money for employers by keeping patients healthier until they qualify for Medicare.
    For poorer people who simply can’t afford the co-pay, it makes sense to cover all or most of it on a means tested basis. I see this as similar to providing free or reduced rate lunches to children from poor families. Just because some families can’t afford to pay for their kids’ lunches doesn’t mean we should provide free lunches for everyone. I also think the community health center model for primary care might work best for lower income people, especially in the urban areas.
    Finally, insurance is intended to cover unpredictable and relatively expensive events, not routine expenses that we all know we are going to incur. Let’s make special means tested arrangements to cover lower income people but encourage the rest of us to buy sensible insurance products that do what insurance is supposed to do. I neither need nor want health insurance to cover the human equivalent of an oil change for my car.

  3. Nate says:

    “(no, I will not follow your typical communication pattern of insulting people who have a different opinion).”
    rbar your making the wrong connection, I don’t insult people who have a different opinion, I insult people who lie and make things up they have no knowledge of. It just so happens these people tend to disagree with me. There are plenty of people who disagree with me that I have never said an unkind word to. Have an honest and educated conversation and I show all the respect in the world, be lazy with your argument and lie and I’ll point it out.
    fine hairs they may be but still hairs none the less.
    “copays/deductibles for routine visits are just not a good idea.”
    Let me share a common…issue I have seen for a number of years, the exact circumstances change to fit the times but the general problem remains the same.
    Doctors office calls and ask for benefits, being that plan docs are 60-100 pages we usually ask them to be more specific. They will start with office visit, then start hunting for ancillary charges they can add on or different ways to bill it to get the highest reimbursement. Some of the less skilled ones will even come out and ask how they need to bill something to get it paid.
    Doctors and patients have a mutual benefit to defraud insurance companies and bill an office visit as preventive when it is not. The thing about healthcare fraud is it snowballs, it doesn’t get better unless it is addresses.
    How do you incent people to stay healthy and prevent fraud, the fraud is already present and only getting worse.
    The only cost effective way to control cost is people want to get healthy or suffer the penalties, I have never seen an incentive that is not eventually abused.
    Means testing doesn’t work, look at the households where kids get free lunch and they still have cable TV and cell phones. We are subsidizing lunch we are paying for bad choices.

  4. rbar says:

    Nate, I am happy to read that you feel that your verbage is appropriate. You should not deride others’ arguments as lazy when you just made the lazy argument par excellence (“Please, what has changed in basic healthcare? You still go to the doctor for an office visit, you still pickup your Rx at the pharmacy. What exactly has changed”). I answered to that, and you don’t even try to defend it, probably knowing that you don’t have a chance on that one.
    Why do you even post? You don’t need to question or adjust your position when debating (some do, and I try to do that), but if you just want to disseminate your point of view (totally OK), just respect basic social norms. Otherwise, you run the risk of weakening your own arguments.

  5. Rob Lamberts says:

    Maggie: Agree 100%. I sympathize with the man’s desire to not spend money; I just don’t like being told to my face that I am trying to make money off of him when I am being reasonable.
    Update: Saw a patient this morning who I ‘forced’ to come in (like the other guy) and noticed oral cancer. He said to me “thanks for making me come in, because I wouldn’t have gotten it seen if I didn’t already have an appointment.” He’s cured and very happy. He’d be dead if I didn’t “force” him to come in.
    Yes, it’s an anecdote, but it makes my point that regular preventive care is worthwhile. It’s why I do my job.

  6. MNinMN says:

    I sent this thread last Friday, when just a few comments were out there, to an environmental consultant friend who I debate health care with (I work for a health plan), and I thought his response was worth passing on…(although I am cursed/blessed with seeing both sides and definitely value a doc who cares):
    I just got around to reading the article. Sounds like the doctor lost control of his inner censor. I’ve had many similar conversations with belligerent clients in my head – but I would try to purge those thoughts before the meeting. It’s particularly funny that the doctor would have so little concern about riling up a patient who obviously has hypertension to begin with.

  7. Rob Lamberts says:

    There was a degree of hyperbole here – the post is not 100% in sync with the visits it’s based on. It is very rare that I do respond to patients. This patient, however, was quite blatant and, to be honest, insulting. He doesn’t like my rules, and complains about it. I defend my rules, and he will live with it or find another doctor. I have plenty of patients who value what I do. I am not going to bend because someone doesn’t want to get $80 out of their HSA. That is my choice, and patients rarely complain.

  8. Mike says:

    I must say I have little sympathy for Rob Lamberts in this case. The basic truth of HSAs versus conventional insurance is that in the latter case patient interests and physician interests are aligned… they both get something out of a visit. But with HSAs the physician’s gain is by design the patient’s loss, and unless patients perceive the compensatory health value, they are going to struggle to figure out whether it is in their interests to incur that loss.
    That’s the whole theoretical point about HSAs… to dis-align physician and patient economic interests.
    I find Rob’s lack of interest or understanding of the patient’s situation to be appalling. If I had a physician who thought and reasoned the way he does, I would definitely not continue to see him as a physician, not because I would make the choices his patient makes (I fully understand the value of preventive care), but because I don’t like unsympathetic and arrogant people (although if he’s good at hiding it, maybe I’d never know.)
    I think the patient had it right, understanding that he was now in an adversarial economic relationship with his doctor. And the doctor, in taking umbrage at how the patient expressed that understanding, is really being quite unfeeling, at best.
    Of course, the doctor believes that he’s worth it, and that he has ethical and medical responsibilities, but he has a responsibility to NOT get angry with an economically struggling patient who, probably not by choice, has been plunged into an adversarial relationship with the entire health system, and is now required to do his own economic cost benefit analysis to figure out the relative value of money in the bank and health services for his body. It’s not an easy equation for anyone to resolve, and in 2010 any thoughtful physician should be alert to this challenge.
    Yes the HSA money is for medical purposes, but the patient still has to figure out whether it is better to spend it now, or save it for something big later. There is no one to help him with that. He’s not a medical economist. He’s just a guy out there who knows that sometimes money in the bank can save your life and sometimes a doctor’s services can save your life, and he’s on his own to figure out which of those optimizes his quality adjusted life years…. an almost impossible question for most people.
    Lamberts lack of understanding of this patients reality is just appalling.
    Oh, and he says “I changed his prescription to something cheap enough to recoup the cost of my visit in two months.” That’s very admirable… taking into account the patient’s economic situation, but the patient had no way to know that this would be the outcome. With Lambert’s attitude, he might just as reasonably have feared a recommendation for a more expensive medication, which no doubt would have been in his health interest but might have failed to take into account his economic concerns.

  9. Nate says:

    “just respect basic social norms.”
    Not all social norms are to be respected. Sexism and Racism for example are socially acceptable in many places, that doesn’t mean they should be respected and accepted.
    On THCB there is a very liberal bias, you will see posters degrade and belittle conseratives all day but at the first mention of something derogatory to liberals shreak in offence. The social norm here is insulting those on the right is ok insulting the left is not.
    If someone is going to write an entire series calling other people liars then fill that with lies what sort of responce do you find acceptable? Glass house and stones right?
    There is, or was, not so sure anymore, a difference between facts and points of views. As I said before I don’t attack people for sharing their point of view, I do attack people for telling lies. These people are telling lies for the purpose of advancing a political agenda. This agenda if successful will have dramtic consiquences on our nation and future generations to come, maybe good maybe bad that is a point of view. But when someone tries to advance this agenda, with life changing ramifications, with lies, your biggest concern is them being called a name? That’s a pretty deadly case of PC right there. The substance matters not as long as decorum is maintained? Personally I rather have a rude truth then polite lies.
    long over due but here it is;
    “1st, you could as well state: what has changed since the stone age? People still eat, talk, cohabitate, and die.”
    If I was talking about eating cohabitating or dieing then the stone age would hold true, I don’t believe we were speaking at that time were we?
    Instead I am talking about the delivery ofmedicine in our indistrial age, which is far newer then the stone age so it doesn’t apply. Since RBRVS in the 60s much in the delivery of routine and basic care has not changed. People no longer trade chickens and grain for an office visit, your pharmacists doesn’t have a bone through his nose and I stand by my point what has changed? I don’t see where you answered the question.
    Out patient care is a broad category if you want to compare 99213 reimbursements whats your point? If you want to compare OP surgery to what use to be done in the hospital that doesn’t usually fall under the HSA, they have usually maxed out by that time.

  10. Rob Lamberts says:

    Mike: It seems as if you judge me on this one post. To most who read my writing, I am very much of a patient-centric doc. This post was written in my blog, so it was meant to be read in that context, which is quite significant.
    It really doesn’t seem like I am the one with the problem passing judgment on others. You are certainly easy to appall.

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  12. rbar says:

    Nate,
    You conveniently “overlooked” point 2 (point 1 is still valid, you point out that some things staid the same, while dismissing change):
    Here it is: “2nd, look at bills for outpatient care in 1970 and 2010. If I need to elaborate on that, let me know”
    So either you alrady know your argument is not defendable, or you unaware of the incredilble explosion of complexity of medical care, and the exploding variety of choice: CT, MRI, PET, advanced chemo, genetic testing, development of medical SUBspecialties, open heart surgery, ambulatory surgery … thanks to progress (some important, some so-so) we are no longer living in the easy health care world of the 70s. And you probably already know that, but will claim otherwise.

  13. hh says:

    I understand wanting him to come in and be seen after almost 2 years, but my doctor can see me 3-4 weeks ago and still want me to come in and pay another co-pay to get a Rx refilled. He does not even see me, I pay my co-pay and the front desk lady hands me the Rx. I try to make my appointments around the same time I need a refill, but sometimes that is not possible.

  14. Chuck says:

    All doctors should make a living wage and repay the schools they attended. No profit no care Supply and demand. As a retired person with health problems I have insurance and medicare enough to keep the economic wolf from the door. I have never questioned a doctor for over charging of services rendered but I do talk with them enough and they recognize I understand economics enough to “questioin” over billing etc. I have fallen into the “do nut hole” two years in a row now, that hurts the budget and I am in hopes the Congress will do some work on this adventure into “poor/improper care” idea. No government control, no government regulation beyond consumer protection, a free competitive medical system will keep costs under control if allowed to work as with all other economic markets and happenings.

  15. Chuck says:

    Insurance is not the problem. Health care insurance is not a “huge” profit making business for the company or the company stockholder. Check profitable businesses on Google. Nationwide insurance sales would cheapen the cost, see auto insurance, life insurance etc. If we could only buy Apple computers in California what would the cost be? If we could only buy oranges in Flordia what would the cost be. Think about it.

  16. Chuck says:

    Check the economic facts and figures from Europe, England, and Canada, costs are high, service is not near the level seen in the U.S. and deaths are higher in some areas. Socialism is and has never worked better than a competition based economic system. The U.S. was founded on free enterprise and it has worked, now with increased Federal regulations, higher spending etc the economy is failing and higher spending is not working even the medical fields will be pushed into ruin if things continue to be torn down by BIG governemt spending, regulation and thoughless ideas. The people should write a Health Care proposal and enact it, not politicans, labor unions or others. Let the people write, they will pay for the system and certainly suffer if it doesn’t work. Without supply and demand Obamacare will take the doctors, medicines inovations etc out of the supply picture and rationing will result. Obamacare no competion in insurance and medical practice yes.

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