Physicians

Y’all Come Back Now, Ya Hear?

Picture 9My recent post on the patient who thought I wasn’t worth paying caused a lot of discussion.  Most of it focused on the financial stresses of a patient in our system – something I am all too well aware of.  But some commenters (one in particular) felt that I was being excessive in my requirements for the patient.

While I think the person was way off-base in their comments, it did get me thinking about a difficult topic: how much is too much?  How often does a person need to come back, and when does bringing people back for frequent follow-up become excessive?  Some psychiatrists bring patients back every month for prescription refills, even patients who are stable.  I’ve had patients complain about physical therapists and even chiropractors who bring them back for multiple visits, incurring multiple charges to the patient.  These may all have merit (I certainly understand the psychiatrist’s perspective), but in each case I have had patients suggest that the clinicians were bringing them back to make more money.

The more I thought about this, the more I realized that there is definitely cause for concern that docs may bring people back to ensure a full schedule.  Since my schedule is full and my income is adequate, I have no need or desire to generate more business than I already have.  I have practiced for fifteen years, so I seldom have a slow day.  This makes the temptation to bring people in these grey areas much lower.  But there certainly are times when people complain about us “forcing” them to come in to be seen.  These areas include:

  • Obvious symptoms of a urinary tract infection
  • Sinus symptoms
  • Allergy symptoms requiring prescription medications
  • Acne

Our policy is that we are unwilling to call in antibiotics unless there is a sore throat  and fever associated with exposure to a documented case of strep in the house (seen in our office).  That is our policy, but reality says that the policy gets bent on a regular basis.  If I know a woman has frequent UTI’s, I sometimes will call in a prescription.  Overall, however, we stick by these rules because we are taking the risk of prescribing a medication, and have often found unexpected findings (such as high blood pressure or wheezing) in cases that sound straightforward.

But how often should a diabetic get seen?  I go a maximum of 6 months for the stable type-2 diabetic, although I usually do every 3 or 4 months.  What about the person with hypertension?  I like to see them every 6 months, but I do sometimes flex to 12 months for the particularly stable patient.  Do I fault people who are more rigid with their guidelines?  Not at all.  Even other physicians within my own practice are more rigid than I am on seeing patients.  I have the biggest practice, though, and so am trying to get everyone seen.

When copays were only $10 or $20, people didn’t argue much with being brought in more frequently.  Now that deductibles and copays are high, the frequency of complaints is much greater.  Ideally, the decision would have nothing to do with the charge, but would be based on what was medically right.  But medical rightness is a very subjective thing, and many doctors will have different standards.  When I get patients from other practices, they often have to adjust to our more rigid rules.  Sometimes they complain, and occasionally they leave to find a doctor who doesn’t force them to come in.

I have enough patients now that I don’t worry about such things.  I practice in a way that I think is best for my patients and have enough business that I don’t have to generate my own business.

Still, would it be better if primary care was cheaper?  I am not sure.  A bad consequence of the $10 copay days is that patients began to think we were worth only $10.  The disconnect of people from the true cost of care made them much more likely to be high-utilizers.  In an ideal world, I would only be driven to see patients based on their medical needs, and patients would trust that this was the case.  But we don’t live in an ideal world.

We don’t even live in a mediocre world.  That means that the argument and misunderstanding will rage on until…well…until the politicians can fix healthcare.

Rob Lamberts, MD, 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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pcpShereef ElnahalpcpcathyMD as HELL Recent comment authors
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Rob Lamberts
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Thanks Brian. It is an interesting contrast to the comments I get on my own blog. This is part of the discourse, I understand, but it does get chippy at times. It’s a good way to develop thicker skin. I have no doubt I am right in this area (my experience tells me so), but it’s hard to get others to see, and it’s not life or death if I do so.

Brian MD
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Brian MD

Rob,
I recently just started reading this blog, and as a PCP with 13 years experience, I agree with every word you have said so far in all your posts. You seem like a competent, caring physician (much like I imagine myself to be) whose experiences and viewpoints are virtually identical to my own.
Just figured I would send you some support to counter some of the flak you’ve been taking, and to let you know I stand with you in solidarity.

Rob Lamberts
Guest

These posts do not represent a single patient encounter. The point of what I wrote (understood well by my regular readers) is this: primary care is undervalued, and as a PCP it sometimes makes me angry. Even those of us who bend over backwards to save money and help people end up being accused by patients of trying to gouge them. This is galling if you are sitting in my chair. I understand that patients have their reasons, and I am sure their attitude is based on experience, but it seems that I must pay the price for the greedy… Read more »

Rob Lamberts
Guest

Again I must point out an irony: I routinely do assess the patient’s financial situation. I always consider the cheapest way of accomplishing something. If I prescribe something that is too expensive to afford (as defined by the patient, not me) I shouldn’t expect the patient to take it. My goal when seeing my patients is to give them the tools to take care of themselves in the best way possible. It would be dumb for a physician to neglect this important fact, and presumptuous to discount it. I take time to explain why a medication is important and why… Read more »

Mike
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Mike

pcp, No, I think the doc’s job is to render “best medical advice” first. But surely, as Rob and others have indicated, if the patient finds it difficult to afford the best option, then the physician has to explore trade offs, maybe an equally good but cheaper option, or maybe even a less effective but cheaper option, or a higher risk but cheaper option. That’s if the patient comes in and has an explicit conversation. If the patient is resisting even coming in, of course there is a more difficult communication challenge, and if they arrive angry and upset you’ve… Read more »

pcp
Guest
pcp

Mike:
That sounds reasonable, but I still don’t get what you want the doc to do in the office. I have patients that I’ve seen every six months for 20 years, and they have had different insurance coverage EVERY single time I’ve seen them. High deductible, no co-pay, 60/40, no insurance, HSA, etc., etc. Again, do you really want the doc to spend part of each visit trying to understand the details of the patient’s insurance coverage (which frequently the patient themself doesn’t understand)?

Mike
Guest
Mike

Thanks Bev. Brian, I’m not a physician or a health care provider (I do medical informatics) so I don’t have the opportunity to sit on the front lines. You’ll have to decide whether anyone other than physicians and care providers should be allowed to comment on these issues. I think it is reasonable that we do. I think you are clearly confusing the economic value of preventive care to the system as a whole, and the micro-economic decision making that the individual must engage in. Even if we grant that every preventive visit that a doctor advocates is carefully considered… Read more »

pcp
Guest
pcp

bev:
Medicare’s allowable for a stool guaic is 4 bucks. Anyone doc who’s charging $50 is a rip-off artist, and should be confronted.
And let’s face it, some people are just takers. It’s anecdotal, but I’ve found those that demanded CTs, MRIs, multiple consults when they had full coverage, are now the ones demanding free telephone medicine when they have HSAs!

bev M.D.
Guest
bev M.D.

Let me say I think Mike is trying to raise an important point here – that is, we are in a transition period between the era of $10 copays and the accompanying expectations, and the new era of increasing financial responsibility of patients for their medical care. This transition is painful – as are many transitions. I think Mike’s point is entirely reasonable, although there is no question that this patient did not represent the viewpoint in the most polite manner. As both an M.D.(who avoids docs whenever possible!) and an HSA holder like the patient, I have to say… Read more »

Brian MD
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Brian MD

Mike, In regards to your comment: “Really? The doctor has his best medical interests in mind, but does he have his total economic interests in mind? Unlikely.” As Dr.Lamberts is a primary care physician, I would say he does. It is widely recognized that regular follow up with a primary care provider is one of the most cost effective measures out there. The $80 he spends per appointment can prevent thousands in hospitalization costs. A good PCP can do the work of several specialists in one visit. PCP’s are ultimately responsible for the patient’s preventative care. Do you feel that… Read more »

Mike
Guest
Mike

PCP, Sorry it’s so hard to understand. I’m suggesting that if Rob considered the possible economic circumstances of his patient he might see that the patient is not necessarily behaving badly because he’s angry or distrustful of his medical views, but because he has a larger set of issues to consider than simply the medical necessity and wisdom of a visit or treatment course. This might enable him to respond less in anger and more in understanding. A doctor is not responsible for allocating a patient’s $80 or $120… but it’s not asking too much that a physician be aware… Read more »

Shereef Elnahal
Guest

This is an excellent example of how population-based evidence could put this kind of dispute to rest. You, as an experienced clinician, are at times comfortable with seeing patients on a less frequent basis, and no doubt these patients do well regardless. However, for the rest of us, we can and should be able to assert the need to see patients if there is evidence-based benefit to doing so. If there isn’t, then such challenges by patients could not be disputed. Please see my article regarding algorithms and guidelines in medicine, as there are many parallels: Please visit my blog… Read more »

cathy
Guest
cathy

pcp, No, the appointment should not be used to look at the patient’s financials. But the doctor should not take personally the questions of the patient. To assume it shows a lack of respect is ridiculous. Instead perhaps assume that the patient understands the reason for their questioning the doctor’s suggestions and let’s go further and assume that the reason is a valid one. At least according to the patient. Would the doctor accept without review an estimate of auto repairs? A patient does not receive an estimate. Again I say it is fiscally responsible for all patients to watch… Read more »

pcp
Guest
pcp

“Wouldn’t the doctor patient relationship be better served by acknowledging that patient’s interests are broader than simply medical interests, and include economic interests?”
I really find it impossible to understand what you’re recommending here.
Are you saying that, instead of taking a history and performing an exam, Dr. Lamberts should have used the patient’s appointment time to review his financial situation: income, investments, debts, etc.? This would have been a better use of the $80?

Mike
Guest
Mike

Brian, I do have empathy and sympathy for anyone who is dealing with clients or patients or customers. As I said, I know it is not easy from personal experience and don’t do it anymore myself. But the fact that YOU (a physician) don’t think the patient’s frame of mind is “the point” is, well, exactly MY point. The patient’s frame of mind IS the point here, and apparently it is not recognized by you or by Rob. Perhaps this is a professional blind spot that you two share? Or shall we simply call it a “perspective” and be more… Read more »