By ROB LAMBERTS MD
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.
Just FYI: Typo alert. I think at the beginning of the 3rd paragraph you mean My not By.
And I wish my doctor was more like you, I go in and still feel ignored.
The patient is a liar. He truly does want you to work for free.
You think patients know how you get paid? You really think he’s out to get you, trick you into “working for free?”
I completely respect this man’s position. You didn’t get him into your office by persuading him you had anything of value to offer him–you literally BLACKMAILED him into coming to your office with a threat to take away the very drugs that keep him alive!
Of course he came in pissed and expecting you were just trying to rip him off! I’d doubt your motives, too, if I’d been blackmailed into showing up in your office!
Do you have any idea why this guy is trying to save his HSA money? Has he been out of work and afraid he’ll never be hired again? Is he getting foreclosed on his house? That money isn’t automatically YOURS because he’s sick, okay? Especially, uh, since he doesn’t seem to _understand_ he’s sick.
You see a tiny slice of this guy’s life and your #1 agenda item is to abuse him for an imagined insult to you. It’s great that you’re really committed to keeping this guy healthy, but he doesn’t know that.
Let’s turn the tables on you. It’s nice that you told him there were cheaper blood pressure pills he could take…but why didn’t you tell him that before? Were you trying to bankrupt him? Were you exploiting him to keep the free pizza coming from the sexy drug detailer who represents the expensive meds? No, you weren’t, no more than he was trying to get you to work for free.
Sounds to me like this patient understands nothing about his condition, and you are just expecting him to trust you that you’re a wonderful doctor with his best interests at heart and he should just open his wallet to you and do whatever you say. That may in fact be true, but why should he believe it? Why should he believe you? Why should he trust you, given that you yourself admit docs are out there who will give him sub-par care?
Furthermore, why should he trust you when you aren’t trusting him? You think it’s ludicrous that you should trust HIM for his blood pressure, but you expect him to just open his wallet to you and let you do whatever you want, even if he doesn’t understand it? Trust is a two-way street.
You say things like “I WILL make you come in,” treating him like a servant who works for you? YOU WORK FOR HIM! And you’re BLACKMAILING him into coming to your office, and you’re bragging about how you will do it again!
I’m sure you’re a good doctor with wonderful motives, and you want to do right by your patients. But your arrogance is getting in the way of doing your job.
You wouldn’t go to a car mechanic who treated you this way. You wouldn’t trust him. I don’t know why you expect your patients to trust you.
“You think patients know how you get paid?”
Yes they do, and if you disagree, you’re saying that patients are morons.
This man was not only a liar, but he was attempting to steal. There is no way to defend his behavior.
Blackmailing? I put my name on the prescription, take the legal risk of the medicine. I am offering a service and he has the choice to stay with me or not. It is bad medicine to not see people at least once a year on these medications. Blackmail?? Hardly.
I think two important issues are how well the doctor knows the patient and how the doctor gets paid. Suppose the patient comes in once a year for a routine physical exam including tests that are appropriate for his condition. Otherwise, he doesn’t come in unless he doesn’t feel well. Suppose also that the doctor is paid a fixed amount per month to provide a defined base of primary care. Under this payment model, issues that can be handled by phone or e-mail should be if they are more time efficient for the patient and don’t needlessly consume the doctor’s time that could be applied to more urgent matters.
I take five maintenance drugs that I receive by mail from my PBM. I can only get a prescription for one year worth at a time. So, each year I send my doctor a letter telling him I need new 90 day prescriptions plus three 90 day renewals for each of the five drugs. He puts them in the mail and I send them on to my PBM. He’s an excellent doctor and a great guy and he accommodates me on this. I see him for my annual physical (including a stress test), a stress echo every other year and for other specific issues as needed. I think it’s dumb to make a patient come in for a prescription renewal unless the doctor really thinks it’s necessary to examine the patient first. Project yourself into the patient’s position. How would you feel if you were required to appear in person to get a prescription renewed? Most of the time, it’s probably not necessary. Tort reform, as I define it, might also be helpful here.
“Suppose also that the doctor is paid a fixed amount per month to provide a defined base of primary care.”
And any patient with a third grade education knows if that is or is not the case.
Dr. Rob has made it very clear that this was not the case here. The patient was lying and was attempting to steal. NO defense possible
I have to say, I have seen doctors who don’t give refills on meds and require patients to come in for every refill. I do think that’s unethical. But there is a limit to which I go until I am unwilling to refill without a visit. Again, if this was for allergy medications, or even migraine meds, it would not be as big of an issue for me. But the medications in question are not risk-free. There is great value in seeing them (at the very least to check the blood pressure), talking to them, and make sure other problems are not bubbling up to the surface. There have been a very high number of times when I had a “routine” visit for medical problems with a patient and found SIGNIFICANT problems that they were not mentioning.
Regardless of what other’s think, though, I am practicing medicine and using my training to do what’s best for the patient. I won’t compromise the quality of the care (which is definitely what this man was asking me to do) because the patient disagrees with me. These patients choose me, I don’t choose them. They are free to choose someone else who practices in a way that suits them. I have to do what’s best and won’t change that.
“Again, if this was for allergy medications, or even migraine meds, it would not be as big of an issue for me.”
But what if, in the interim, the patient had started taking another med from another doc with a serious interaction with the one you are willing to prescribe without an office visit?
How much does a prescription refill appointment cost, and how long does it take?
I like the “Another Anon!”
A routine visit costs about $80 (depending on how much is done, it may be more). I spend 15-20 minutes with them and they usually spend about an hour in my office total.
Robert: Maybe (although with allergies I don’t think that’s an issue), but I really hate to waste people’s time. I really have plenty of patients on my schedule and don’t have to invent reasons to see them. I am willing to take a small risk (which I do every day anyway). I disagree, by the way, about the person lying. I sympathize with him in the financial situation, but was definitely insulted when he didn’t think I was worth spending time and money to see.
Dr. Lamberts,
I honor your committment for trying to keep this patient healthy. Now days you do not find many doctors that spend the time or care to spend the time on educating their patients. I work as a Registered Nurse and I find it very frustrating when we educate our patients on how to take care of their illness and then next time we turn around our patient is readmitted in the hospital with the same diagnosis. If a patient has hypertension or high cholesterol they should be seen periodically by their doctor because that is your medical license, that patient is under your care. Great job on being firm with your patient. We need more doctors like you. Elizabeth Grant Registered Nurse
Barry, your doctor doesn’t make you come in for the renewal because he checks the records and sees that you have been in for your physical less than 12 months ago. Try skipping one of those physicals and I bet he’ll make you come in. He would be negligent otherwise.
I don’t think anybody is trying to steal anything. Unlike the experts common wisdom, most patients don’t like going to the doctor, and either don’t understand enough to realize that you need to be seen at regular intervals, or choose to take their chances, particularly if they feel fine on their meds.
As long as medicine is practiced withing some minimum quality standards, people will have to inconvenience themselves and show up at the doctor’s office once in a while. I don’t thing it has much to do with driving up volumes (isn’t there a shortage of docs?) or with tort reform. It’s just good health care and trying to do no harm by recklessly prescribing over the phone. It looks though, that in the name of consumer convenience, we may very well be headed in this unfortunate direction. Maybe we will revisit the value of convenience after several “perfectly healthy” folks drop dead from convenient iPhone prescription services.
Rob, this is Exhibit A in why “user fees” are a really stupid idea & why the HSA is a REALLY stupid piece of public policy.
People shouldn’t be fretting about relatively small dollars, and deciding whether it’s worth seeing a doctor–especially if they are on the road to serious problems as this patient is.
And separating the cost of the (probably cheap generic) drugs and lab tests from the cost of the physician visit is equally bad policy.
That’s why both Kaiser Permanente style integrated plans don’t separate them out, and why value based plans (like Pitney Bowes) cover those preventative care visits for $0.
And it goes without saying that this is only an issue for the people for whom the $80 or so you’re charging for an office visit actually means something….
Which is just another reason why primary care is a disaster in the US compared to most countries…
The first anon makes some excellent points that bear reading closely and thinking about.
Put aside the perhaps hyperbolic use of the word “blackmail” and look at the fact that this patient does not in fact understand much about his own condition. He is already not well, but doesn’t understand it and thinks he should only come in when he is “sick,” which appears to mean he has a new disturbing symptom causing him pain or diminished functioning. In short, he doesn’t understand the preventive value of primary care.
I agree with Matthew that he is a perfect example of why giving people more skin in the game is often not a good idea. As Maggie Mahar is fond of citing, there is plenty of evidence that people get stingy with useful care as well as with unnecessary care. The new HSA designs with first dollar coverage for preventive care help to address that problem.
This guy apparently doesn’t understand much about medicine and health, and so it wouldn’t be surprising at all if he also doesn’t understand very much about how doctors are typically paid (and what they don’t get paid for), or about this doctor in particular. Unlike Rob Lamberts and “robert” the commenter, I see no reason to think this guy has any real thought about forcing the doc to work for free.
About 6 years ago I started working for an HMO that has a portion of its network consist of capitated multi-specialty groups. I can tell you for a fact that most people seeing one of these capitated physicians do not know that the physician is capitated. Conversely, I don’t think patients typically think through the renewal of a prescription and see that as “free labor” from a physician. They think: This guy got paid $80, or $160, or whatever, last time I saw him for 20 minutes, and as part of what I paid I should be able to get refills taken care of. It isn’t crazy at all for a patient to think that way, even though doctors don’t.
There are lots of things we buy that we expect a service relationship for after the point of sale. Why can’t the purchase of an office visit bring with it certain service obligations afterwards, such as a certain number of refills? Is it really ridiculous for a patient to expect that?
Obviously, Rob’s points about what is medically advisable all still hold. I’m just talking about the anger physicians continually feel about not getting paid for every finger they lift. It’s making doctors sick and bitter, and it’s making them worse doctors.
When we do finally and decisively break from a fee for service model, future physicians are going to look at this period as backwards and barbaric.
I don’t quite understand what the patient did not understand. Maybe he just forgot….
Refills and renewals are two very different things. As part of the service obligation, prescriptions for chronic stuff do come with a certain automatic number of refills, for which you do not need to see, or even call the doctor.
Renewals on the other hand require a call and usually a checkup at least once a year and sometimes more often. I think most patients know that and most doctors make that very clear when they prescribe. Nevertheless, for various reasons, financial or just hating to go to doctors, people would rather have their scripts renewed forever if they feel fine. People would rather also call the doctor they haven’t seen in 5 years, and have him prescribe antibiotics over the phone.
A visit to a PCP shouldn’t cost $80. Those HSA accounts are the scourge of the earth. Primary Care visits, preventative or otherwise, should be paid in full (minus copay) regardless of HSA arrangements. It’s nickels and dimes for insurers and a significant barrier for many patients.
Nobody is going to gorge themselves on daily visits to PCPs.
Margalit, I was running together renewals and refills. Even though the physician and the medication bottle say how many refills there are before a renewal is needed, it’s easy for a patient to think: a “renewal” really just gives you more refills, with the added cost of seeing a doctor again. Obviously, there is typically a medical reason to see the doctor, but as with the guy in this example, plenty of people don’t understand or reject the expressed medical advisability of more doctor contact in order to get more drugs dispensed.
As you say, there are various possible reasons why a person could want to keep getting refills and not see a doctor to renew. Putting one over on the doc and consciously “stealing” labor is not one of the top 3 and maybe not top 5, contrary to Rob’s implication and Robert’s explicit assertion that it is necessarily present.
jd – I’m curious. Does the portion of your HMO’s network that receives capitated payments keep patients just as healthy for less money that the providers who receive fee for service? If so, how much is saved by driving out excessive and unnecessary utilization? I note that the Massachusetts AG found that some capitated payment contracts actually turned out to cost more than the same care would have cost under fee for service.
What an experience! Well, at recent times, there are really a lot of patients that if possible, any medications are for free – no charges, and no hassle as long as they will be treated and I’m sure that is not fair to any of the doctors or any clinicians as well.
“Yes, we have an HSA, but we are trying to hold on to that money.”
He has a HDHP because that’s all he can probably afford and this statement shows that the deductibles are what people fear, or should fear in these plans. HDHPs show a failure of the system to control costs but are designed to keep insurance company profits from eroding when they fail to control costs. They are sold to people who do not have adaquate resources to handle the downside of an illness.
You’ve indicated that the patient has hypertension and a high cholesterol, and is on treatment for both.
Since there is very limited evidence for using statins in primary prevention with a NNT over 100, perhaps he could save even more money by not taking cholesterol lowering medication.
And of course statins have been associated with agression as a side effect.
You’ve indicated that the patient has hypertension and a high cholesterol, and is on treatment for both.
Since there is very limited evidence for using statins in primary prevention with a NNT over 100, perhaps he could save even more money by not taking cholesterol lowering medication.
And of course statins have been associated with agression as a side effect.
You’ve indicated that the patient has hypertension and a high cholesterol, and is on treatment for both.
Since there is very limited evidence for using statins in primary prevention with a NNT over 100, perhaps he could save even more money by not taking cholesterol lowering medication.
And of course statins have been associated with agression as a side effect.
You’ve indicated that the patient has hypertension and a high cholesterol, and is on treatment for both.
Since there is very limited evidence for using statins in primary prevention with a NNT over 100, perhaps he could save even more money by not taking cholesterol lowering medication.
And of course statins have been associated with agression as a side effect.
You’ve indicated that the patient has hypertension and a high cholesterol, and is on treatment for both.
Since there is very limited evidence for using statins in primary prevention with a NNT over 100, perhaps he could save even more money by not taking cholesterol lowering medication.
And of course statins have been associated with agression as a side effect.
You’ve indicated that the patient has hypertension and a high cholesterol, and is on treatment for both.
Since there is very limited evidence for using statins in primary prevention with a NNT over 100, perhaps he could save even more money by not taking cholesterol lowering medication.
And of course statins have been associated with agression as a side effect.
You’ve indicated that the patient has hypertension and a high cholesterol, and is on treatment for both.
Since there is very limited evidence for using statins in primary prevention with a NNT over 100, perhaps he could save even more money by not taking cholesterol lowering medication.
And of course statins have been associated with agression as a side effect.
You’ve indicated that the patient has hypertension and a high cholesterol, and is on treatment for both.
Since there is very limited evidence for using statins in primary prevention with a NNT over 100, perhaps he could save even more money by not taking cholesterol lowering medication.
And of course statins have been associated with agression as a side effect.
I’m guessing that the patient is also seeing $80 for 20 minutes and thinking, “that’s $240 an hour!” and for most people that seems like a whole lot. And it’s not at all hard for most of us to think that someone might insist on a visit for the profit motive.
One thing that is lost in this discussion is the fact that the colonoscopy and stress test last year cost far more than my visit cost. The per hour cost of one of these visits is in the thousands. People will wait to get sick and go to the ER and pay $400 (or far more) for a longer wait and more unnecessary tests. I agree that the cost is a barrier for these people to get the care they need (although for this patient, I honestly think it was a case of someone not valuing my care). But I still wonder if the barrier is in the people’s heads, not in the cost. People drop $80 for an awful lot of things without thinking, and if they have the money they are willing to pay it as long as they value the service enough. Many docs wonder if the real culprit wast the HMO all-you-can-eat buffet $5 copays of the past that devalued primary care in the eyes of the patients. People started thinking we were only worth $5 and so now balk at the real cost of these visits.
Yes, a lot of people drop $80 for nothing. But an awful lot don’t, too. Remember, the average household income in the US is about $46,000 or so. And that means there are a whole lot of households making less, sometimes far less. Maybe the patient values your work, but not up to $240 an hour?
Let’s accept that you certainly weren’t making the patient come in primarily for the money. How would your behavior in the face of the patient’s have been different if you had been doing it primarily for the money? How would it have looked different to the patient?
Didn’t I read somewhere a couple years ago that a fair percentage of doctors don’t have a primary care physician? Is that because they don’t think it’s “worth it” to have one?
I can think of a doctor blogger who’s bragged about self-prescribing and not needing another doctor to oversee his care. Does he think a doctor is “worth it”?
Do you see your own doctor once a year? If not, why not?
The patient clearly valued taking the prescribed medicine, but did not value the care and opinion of the doctor who prescribed them. We know nothing of the cost to the patient of the previous visit.
We also do not know why the patient was able to go 18 months withour a visit. Perhaps he had already benefited from the doctor’s discretion in letting a visit slide for a period of time.
We also have a bunch of comments from lay people who do not have the ethical burden or the professional burden that the doctor has in prescribing controlled substances. It is wonderful that ibuprofen, once prescription, is available over the counter, but I just saw a 45 year old woman kill herself with too much ibuprofen taken for for pain.
Common drugs for hypertention and high cholesterol can be purchased in Mexico without a prescription. Is that what you all want? If not, then there is a price for the doctor’s involvement, advice and liability in your care. Pay it.
Matt and Peter why does basic match and common sense not apply when it comes to healthcare?
“why the HAS is a REALLY stupid piece of public policy.”
To cover an $80 office visit through insurance cost $100 in insurance premium. Maybe if your a ninny liberal that can’t take responsibility for your own finances this makes sense. For most adults saving the $20 would be the logical thing to do. You also seem to forget our healthcare system and every other developed system is facing a consumption crisis. Other systems have responded by rationing care we are on our way to rationing care. We obviously can’t afford unlimited use, how exactly do you propose limiting spending if your going to give everyone free unlimited care?
People are going to make poor decision no matter what, forgoing an office visit becuase you want to save your HSA funds is far less harmful then spending your insurance premium money on a smoking habit like a large portion of our poor do.
There was a recent survey that gauged the financial inteligence of liberals in regards to deficit spending and basic econ, needless to say around 40% or more failed. I’ll wager its that same 40% that can’t grasp why HSAs work and are such a good idea.
Peter your grasp of insurance is somehow worse then it was 2 years ago, like your unlearning or something. I have a little challenge for you, I want you to sit and actualy think through the garbage you post, explain to us here how HDHPs protect carrier profits when they fail to control cost. If you had even an elementary comprehension of insurance you would know it is the exact opposit. Cost is mainly large claims, failure to control cost would mean your not controlling your large claims. If you sell a HDHP your forgoing 30-50% of the premium but only removing the small claims which usually only make up 20% of the cost. Contrary to what you said maggie, oops peter, all the clueless comments make it hard to tell you apart, HDHPs reduce profit when cost is not controlled.
Humana and Aetna for example just eliminated a number of their HDHPs becuase they were supposedly losing money on them. If a carrier can’t control cost they want to assume as much low end risk as possible to offset the high dollar risk.
Have at it peter please try to defend your comments.
“That’s why both Kaiser Permanente style integrated plans don’t separate them out,”
Matt what are you talking about? Kaiser charges for their drugs just the same as any other plan and also charges for their lab test, they might do them at the same place and fill your Rx as you leave but they sure as hell are separate.
We adminsister a number of section 125 plans in CA. I’m very familiar with Kaiser becuase we have major subatantation issues with them. Members send in receipts for Rx or lab co-pays ever day. Kaiser receipts don’t have all the information that ideally would be on a claim for reimbursement. People with Kaiser for numerous reasons still use other pharmacies.
Is this what your hoping for in America Matt?
“Meanwhile, the International Monetary Fund issued a blunt report on government debt control.
Developed nations have overpromised, the IMF said, particularly on pension and health benefits for an aging population. The choice is to cut spending and raise taxes, or find ways to boost growth.”
A bunch of meaningless promises and future generations enslaved to your debt? Sooner then later people need to grow up and start caring for themselves. If the small step of HSAs is to hard to take then we have already lost, we mine as well give up now. Spending cuts, tax increases, and personal responsibility 100 times harder then the basic HSA is not a question, it is comming.
I think everyone has made a bunch of good points; I even find myself agreeing with MD as HELL and part of Nate’s comments. I myself have an HSA with 10K (yes you read it right) deductible and I do think carefully before I go to the doctor. The bit about hanging onto it is because, of course, it accumulates tax free but,with the small allowable contributions, it can be rapidly used up with regular medical care.
And, just as a comparison, today I paid $74.90 for a rabies shot for my dog – and I have one of the cheaper vets in my area. I do not think $80 is unreasonable for an office visit. Those who do are, as someone said, used to $5-$25 copays and “don’t get it” about the cost of medicine.
I wonder that no one draws the obvious conclusions, namely that:
1. copays/deductibles reduce unnecessary AND necessary care, as at least one empiric study has already shown
2. consumer driven medicine working rationally and to the patient’s favor is a delusion FOR MANY if not most patients. Yes, some may very well be able to handle it well, but many patients lack time and/or dedication/ motivation and/or intellect to navigate the health care system/mess, and that’s often reflected during (my always patient centered) visits, when I explain pros and cons of various options: “Well, what would YOU do?”
rbar your 10 years behind, no one knowledgeable in healthcare financing is saying cost sharing does not effect necessary care. The problem is you made the easy conclusion then stopped. No cost sharing is not a sustainable option. $10 OV Co-pay is not a sustainable option.
HDHP are the best proven alternative available today that might be sustainable. Its not guaranteed they will work but it is guaranteed they work better then what we where doing.
The fact missing from discussion is how Americans managed to pay 50% of their healthcare out of pocket with no problem but now anything over 15% is unthinkable. Are you claiming American society has dumbed down that much in 40 years? Where our grandparents really that much smarter then us?
Nate,
Are you seriously claiming that health care expenses and choices now are remotely similar to what was offered 40 years ago? In that case, I am sure you are going to tell me about the good ol’ times when the local barber did the CABG. Of course after our greatgrandparents made an informed choice against the angioplasty that the plumber had offered …
I think that high deductible plans may work somewhat against overutilization, as a blunt instrument … but there are other solutions, the easiest being adjusting reimbursement structures. As opposed to some progressives, I do believe that overutilization is partly patient driven … but stuff like this is at least equally important:
http://journals.lww.com/neurotodayonline/Fulltext/2010/05060/Deaths,_Complications,_Higher_Costs_Accompany.1.aspx
Barry:
“Does the portion of your HMO’s network that receives capitated payments keep patients just as healthy for less money than the providers who receive fee for service?”
In a word: Yes. It’s important that we aren’t just talking about capitation, but large multi-specialty groups that are doing it. Not to go into too much detail, but different groups also have different arrangements (basically, involving how much coordination we do with them on quality and whether we capitate only the professional expenses or the entire cost of care). The more alignment there is with quality in our capitated payments the better, as a general though not absolute rule. And obviously, the less market power the entity has the better, in terms of our capitated rates. If you are dealing with a huge hospital+clinic system that has you by the short hairs, capitation isn’t necessarily going to save any money.
“how much is saved by driving out excessive and unnecessary utilization?”
Even though I am writing anonymously and haven’t “outed” my company, I can’t give specific numbers. We’re talking about small improvements in quality and small reductions in cost. Significant, but not (yet) the kind of 30% savings that we keep reading is possible given all the waste in our system.
And yes, the savings are reflected in lower premiums for products that rely most heavily on those parts of the network.
“A visit to a PCP shouldn’t cost $80.”
What planet do you live on?
Evaluate and discuss two serious, chronic medical problems; write and discuss at least two prescriptions; order appropriate lab tests; review and notify patient of results; follow up on abnormal tests; discuss needed health maintenance in addition to the chronic problems. All with a 50-60% overhead!
Margarit, I’ve always appreciated your posts, but now I think you must work for the AMA: you obviously think primary care is worthless.
No No No… Robert…. You misunderstood….
The doctor should get paid probably more than $80 for such visit, but the insurer should cover it fully, for primary care only, even if you have an HSA.
Thanks for the clarification.
rbar,
yes I am telling you exactly that. 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. Or are you that clueless to what a high deductible is? High deductible plans don’t come into play with hospital care and the major services that have seen such innovation. In fact HDHPs usually have lower out of pocket meaning they impact large claims even less.
Please get off the slogans, what exactly does changing reimbursement structres mean, give me details there Obama, sound bites don’t cut it on THCB. How do you propose incentivising members to ration care?
“but the insurer should cover it fully, for primary care only, even if you have an HSA.”
WHY MARGALIT WHY? Why in the world should they do that? Who do you think pays for the office visit if insurance covers it? Why pay $100 in premium so your insurance company will cover an $80 bill. Just once I want to hear some liberal answer this question, it doesn’t even have to be a good answer, just any slightly logical reason why we should pay a 20% surcharge to have someone else right the check.
Nate, first of all, for most folks it is not a $100 markup for a straight $80 bill. If the insurance is obtained through an employer, and the employer purchases an HSA instead of regular insurance, you will not get a pay raise for the difference in premiums. The only difference will be in the percentage that is not deducted from your salary. If it’s 50% than the difference for the employee is $10, and even that is not entirely correct because of the pooling. Basically, the individual employee does not save much, if at all.
Even if you buy your own coverage, people tend to be penny wise and pound foolish and if the insurance doesn’t cover it, they just won’t go to the doctor until they are really sick.
You could argue that it is in the best interest of the insurer to cover these small charges in order to prevent the big ones sure to follow. Of course if the insureds are short term customers, than why should the insurer care?
If everybody is trying to set up all these wellness programs, wouldn’t it make sense to encourage preventive care and regular doctor visits for those with chronic conditions?
Whether you like it or not, for too many people $80 is prohibitive, and for many more who don’t understand the importance, or are just looking for an excuse not to go to a doctor, $80 may just be enough. Makes you wonder about the assertion that utilization is driven by patients, doesn’t it?
You could of course decline to be everybody’s nanny, but sooner or later these folks will reach Medicare and the chickens will most definitely come home to roost.
So the cost of our entire healthcare system starts with the admission and acceptance that most people are to stupid to take care of themselves? Do you realize with you start building from here any system is doomed to failure. There is nothing you can do to control cost if your going to accept people are incapable of caring for themselves. Any sustainable system relies on people looking out for their best interest.
Stock scams, fraud, waste, graft, corruption in general is all built on people not caring and not being responsible. If your going to relieve individuals of all responsibility for the cost effective delivery of their care it will never be cost effective.
If someone’s OOP is limited to $5,950 and they know they are going to hit it why not go to the ER every weekend instead of a normal doctor? Why not take a brand when an equally good generic is a fraction of the price? Why temper your spending at all if your not liable?
To your first point that is not true when an employer reaches their threshold, I see many employers today who have reached a point where every dollar increase is passed on tot he employees.
“Makes you wonder about the assertion that utilization is driven by patients, doesn’t it?”
Not at all, I know for a fact those patients with low cost sharing drive utilization. I have seen first hand the effect moving to a $200 ER co-pay had compared to when it was equal to urgent care. I have seen first hand how 2 tier, then 3 tier, and now 4 tier co-pays have changed utilization. When they are spending other peoples money patients make expensive and poor decisions. When spending their own they also make those same poor decisions but the economic impact is not nearly as bad as when they are spending other peoples money.
The solution to healthcare cost is not to accept one of the major failings, patient responsibility, we must educate them and change this behavior. This is public housing and welfare all over again, a bunch of liberals that never held real jobs think they can legislate results while ignoring the problems that cause it in the first place. Healthcare reform 2010 will be no more successful then public housing, welfare, or medicare.
Nate, why do we force all kids to have their immunizations before entering a classroom? They should be responsible enough to immunize their children.
Why do we force people to buy car insurance, and house insurance if they get a mortgage? Why do we encourage people to recycle by giving them special containers? Why do we have traffic lights and speed limits?
Why not everybody be responsible and do the right thing?
Because people will sometimes do the right thing on their own and sometimes will need a bit of encouragement from society. And society is just looking to protect itself from people that are not too eager to do the right thing.
Same with preventive care. People are not stupid, but they may need a bit of prodding to take care of themselves and save us big Medicare expenses. I don’t see anything wrong with that.
I think we should try it. I think Medicare is going to try free preventive care and I think a bunch of private payers are trying all sorts of wellness programs. I’m pretty sure they wouldn’t bother if it didn’t save them a quick buck.
So maybe we can build a sustainable system based on “social responsibility” instead of just personal responsibility, which sounds more and more like personal discrimination.
Interesting discussion. I see the points of both sides. On one side, why not make the least friction for the course that will save money (primary care)? On the other: people value what they pay for things. If you can get a free computer whenever you want, you won’t think computers are valuable. Again, the $10 copays devalued primary care physicians in many people’s eyes. It is strange to me, however, that insurance companies don’t do things that promote cost savings. They don’t shunt people away from the ER and to primary care when it would be easy to do so if they really wanted. It speaks to the fact that they can pass on cost and not feel them in their profits.
I did a follow-up post on the subject of return visits: http://distractible.org/2010/05/16/yall-come-back-now-ya-hear
I am not a medical expert, I am probably like your patient in many ways. I also have an HDHP and HSA account for my family; we put into the HSA each year an amount equal to our deductible. When we don’t meet the deductible, we roll the balance forward; when we exceed our deductible, we utilize what is left in the HSA from previous years. Though my children visited the doctor regularly, my husband and I only went when we suspected a problem. Because the HDHP plan we have covers most preventative and wellness care with $0 out-of-pocket expense to my family, my husband and I now see a PCP at least once per year (more as needed) and I am certain we are better off for it. I fully believe that the quality of care I and my family receive is high and that with rare exception, the doctors we have visited have our health and well-being in mind.
However, I am convinced that ONE doctor saw my family as a revenue stream in a down economy. I have two children who saw the same pediatrician for more than 3 years. The same doctor gave them their annual physicals, their vaccinations, provided care when they were sick, prescribed antibiotics or other medications as needed and made referrals to other specialists if necessary. We saw this doctor 2-4 times per year, per child and all was well until last year. I brought one child in for kinder vaccines and the doctor noticed a wart on my other child’s hand and offered to treat it right then. I consented and expected to pay a separate doctor’s visit (~$120), but instead I was charged over $700 for ‘hand surgery.’ When I called the doctor’s office to correct what I believed to be an innocent billing error, I was initially told ‘don’t worry about it, the insurance will cover it.’ An annual physical for the other child included a discussion about his diet (as did every previous physical). I was billed for two separate office visits for the one appointment: one for the physical, covered in full by the insurance plan, and one for a ‘supplemental nutritional evaluation’ charged to my HSA. Later that year, I made an appointment with the pediatrician to obtain ADHD medication for my older child. Since the psychologist (referred by the pediatrician) had been working with my son for 2 years, and because she forwarded my son’s medical file, diagnosis and recommendations to the pediatrician ahead of time, I expected to leave the pediatrician’s office with a prescription, and of course, I expected to pay for this office visit. Eight weeks and three office visits later ($360), I finally received the prescription from the pediatrician.
From the doctor’s perspective, all these charges are reasonable, from mine, they are excessive and it has made me skeptical. This is unfortunate because the overwhelming majority of doctors are like you; they are providing responsible care and have a reasonable expectation to be compensated. There are a number of issues with high deductible plans, ranging from structural problems (incentivizes underutilization of medical care), consumer-driven problems (it is easy to save too little the HSA leaving the insured with inadequate resources for basic medical needs) and provider-driven problems (I find billing errors are most common). Add that most HSA administrators default to automatic withdrawals for provider payments such that the insured sees the lump sum deductions from the HSA before receiving the EOB statements detailing the charges and you have a situation where the average consumer is very vulnerable. It is a frustrating situation that can easily become overwhelming and leave one feeling powerless. In my own experience, I have been charged for xrays that were never taken, I have been charged for tests not performed, and most commonly, I have been charged by two doctors for the same image/test/service provided by only one. To me, it seems this comes from a lack of coordination or communication in the back offices of complementary practices. For the most part, if the distributions are not automatic, it is relatively easy to correct, though incredibly time consuming. In the instances where there were errors and the provider was paid automatically before I could review the charges, I was unable to get the billing corrected and obtain credits or refunds (including the $700 ‘hand surgery’).
To a point, I can sympathize with the patient’s initial frustration. I can understand wanting to ‘save’ the HSA funds. I use my HSA account all the time, but I scrutinize the charges, often requesting cost information and disclosure of any incidental charges that may be added from the doctors upfront. Since going to an HDHP and HSA account, I have experienced 75% of my initial bills with errors of some sort; I have learned arm myself with as much cost information ahead of time as possible and to be wary of unexpected charges/expenses. I believe your patient was coming from a similar state of mind. He was off-base, he had gone too long without a follow-up visit, you were right to be upset and you made your point well. He is clearly unaware of the true nature of his illness or the true costs of his treatments, costs which have been obscured. No matter how you slice it, health care has become very expensive. its an unfortunate reality we must all work within.