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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  1. 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.

  2. 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.

  3. 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 actions of other physicians.
    I am not whining, and I am not saying my patients are bad. I am simply saying that, being a person myself, I react emotionally to this. Please read the rest of my writings on “being a doctor” if you want to understand more of what I see as a very important point: the essence of medicine is the human interaction between doctor and patient. Build this relationship (really – not just as a consumer/provider relationship) and you will fix much of what is wrong in health care.

  4. 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 I am ordering tests. This way they can understand the true cost/benefit. I also don’t routinely prescribe brand-name medicine when I see that a patient has insurance. I ALWAYS choose the cheapest alternative (as long as it does what is needed). This is not only “nice” to the patient, it is good medicine.
    Mike, the problem is that your first entry into this discussion was very much the same as what you condemn doctors acting toward patients. You came in assuming you knew what was going on and that you understood my perspective. Ironically, you came condemning me of thinking I knew what was going on and that I understood my patient’s perspective.
    In that sense, you made your point. If your point was: “don’t act like I am acting right now when you are doctoring,” I could not agree more. Docs must always consider all sides of the issue and understand who is paying the bill. In the same way, you should not barge in and assess me as being a patient-hater or a greedy doctor when you have incomplete information. If you doctor in the way you comment, I suppose it’s a good thing you are in informatics, not clinical practice.

  5. 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 got a similar problem.
    I’d turn around your question and say “do you really think that it is possible to deliver the best care without an understanding of the patient’s ability to pay?” Because,insurance has made such care possible for a long time, and increasingly that’s just not possible. You may not need to know the details of every patient’s changing insurance, but when patients are resisting, when patients are splitting pills to get to the end of the month, when patients are angry or resistant about what they see as an extra visit, I think that directly impacts the quality of care they are receiving, and yes, a competent physician ought to be aware of that, and take account of it at least in emotional terms (understand why a patient might be upset) and we hope also in care terms (seeking affordable alternatives).
    The patient doesn’t like having to care about money in health care and neither does the physician… but there it is. Insurance plans have changed. An optimized medication list and preventive care schedule isn’t worth beans if the patient lacks the economic ability to comply.
    Physicians who think their job doesn’t include an economic dimension are truly living in the past. For heaven’s sake, compliance, or, as some of us prefer, “adherence” has always been an issue. Most physicians (we know from studies) think of it as “the patient’s problem”, but if you take a systemic view of medication adherence, of course it is your problem and the system’s problem too, and patient’s don’t fail to adhere just because they are bloody minded or stupid, and it would be intellectual malpractice to say that is all there is to it. They have reasons and getting inside of those reasons is how we improve adherence.

  6. 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)?

  7. 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 and always a net economic plus, that does not mean that the expenditure is the patient’s best expenditure of money. For example, those expensive things that you are trying to prevent may very well be insured under an HSA plan. The patient’s HSA saving money is for routine care under a certain threshold. So the patient does not absorb the cost of a catastrophic event. This, in economic terms, may reduce the patient’s incentive to spend to avoid it.
    I think I expressed pretty clearly that I do not think that the physician “must now also figure in the patient’s econmic wants and need into the equation” but rather that understanding that the patient now HAS a new set of economic circumstances might enable you to interpret his anger differently… perhaps as confusion, frustration, lack of ability to understand the value of the proposed visit or treatment. Again, not to excuse rudeness, but sometimes awareness changes our understanding of what emotions people are expressing.

  8. 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!

  9. 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 I myself have been shocked at the cost of medical care – not necessarily routine visits, but specialist charges, imaging charges, tacked-on ancillary charges (such as $50 for a stool guaiac test), etc. One does become suspicious.
    On the other hand, when my daughter grumbled the other day about having to see her ob-gyn to get a refill of BCP’s, I was able to cite this post as to why this is necessary. Patient education at the time of first prescription may go a long way toward mitigating these resentments.

  10. 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 preventative medicine is a poor use of healthcare dollars?
    I also take issue with your attitude that primary care doctors, in addition to all the other burdens that are being heaped upon us, must now also figure in the patient’s econmic wants and need into the equation. Our job is to maintain health and prevent disease, not to be the patient’s financial adviser. That being said, I am sensitive to what costs a patient may incur when I prescribe medication and order tests, and discuss it with them in an attempt to minimize their expense, and I usually discount my fee for patients with no insurance to an amount similar to what Dr. Lamberts charges.
    The patient in this story had gone 18 months without coming in to the office. I have alot of patients who balk at coming in, but even the most stubborn realize it is completely reasonable to ask them to follow up annually before prescriptions are renewed. The patient’s behavior was out of line, and were I his PCP, I would have too much on my plate to start psychoanalyzing him so I can see his point of view.
    It’s nice that you can sit on the sidelines and make excuses for this patient’s behavior. Spend some time on the front lines of providing primary care and you will change your tune quickly.

  11. 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 that at that price point his patient may be trying to figure out that issue and probably having a difficult time of it, even if he fully agrees that in a “money is no object” world the doctor has his medical interests at heart.
    The patient (often) no longer lives in the “money is no object” world in which the only consideration is whether the doctor knows what the best medical course is.

  12. 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 on the business of health care in America:

  13. 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 their health care dollars. And doctors should respect that and assist their patients with as much information as possible so that a good health care decision can be made. The days of worshipful patients bowing unquestionably to the white coats is over. I hope.

  14. “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?

  15. 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 neutral about it?
    It is a very different thing to be receiving a service of uncertain but presumptive value for a price of $20 versus $100. The latter is objectively painful for many people.
    Should patients not be rude? Of course. Should professionals try to understand the sources of rudeness and anger when they encounter them repeatedly and the cause seems understandable? Well that seems reasonable to me too.
    “Even if the patient feels the visit is a waste of his time and money, he should have the common decency to act in a civil and mutually respectful manner to Dr. Lamberts,” Well, yes, of course. Politeness is a virtue. But between walking away altogether, or accepting that the doctor has only his best interests at heart, isn’t there a middle ground that takes into account price and costs?
    “… who only has his best interests in mind.”
    Really? The doctor has his best medical interests in mind, but does he have his total economic interests in mind? Unlikely. Unless you or he are able to acknowledge this dilemma, and the fact that patient’s must wrestle with it, I don’t think this conversation is going anywhere.
    “The patient’s adversarial posturing and complaints are insulting, convey a lack of respect, and are toxic to a doctor-patient relationship.”
    Well, it depends of course on how it was expressed… adversarial posturing can be real, or it can be imagined, or it may be somewhere in the middle. The fact is that patient and physician interests are not perfectly aligned, and the patient is awkwardly and perhaps rudely expressing this understanding. He may have done a bad job of expressing it, but I don’t hear you acknowledging it either. Just the opposite. You swear that the doctor has only the patient’s interests at heart.
    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?
    But that would raise some pretty big questions wouldn’t it?

  16. My families minimal, health insurance costs us over $600.00 a month with $5000.00 deductible per person. It is the best we can afford. Now add the $120.00 office visit fee (it is over $200 in our area!) and the cost of medications. That totals over $800 a month to stay healthy! A patient has the right to question the need of regular visits. It is fiscally prudent. With the median household income holding at approximately $4300 gross dollars a month, that regular visit can add up to a real burden.
    I would also like to add that respect goes both ways. Many doctors assume they are far more intelligent as well as more educated than their patients, and speak in patronizing tones. This makes it difficult for the patients to ask the questions they came to ask. A defensive doctor is even more difficult to talk with. Questions should not hurt your feelings. You are there to provide a service for which you are paid. I am sorry your client was so hostile, but as a family that is struggling with a medical crisis, I truly understand his “back against the wall” response.

  17. Brian, re your painting analogy: remember, the patient has agreed to pay for the service before it starts. Except the patient also doesn’t always know how much the service will cost, even if s/he asks. So try a restaurant analogy: you agree to pay (or even pay ahead some), knowing there may be extra charges beyond what you saw on the menu, before you get to taste the food.

  18. Mike: Why don’t you take a small amount of the empathy you feel for the patient and apply it towards Dr.Lamberts?
    I’m sure alot of your insights into the patient’s frame of mind are accurate, but that is not the point. Even if the patient feels the visit is a waste of his time and money, he should have the common decency to act in a civil and mutually respectful manner to Dr. Lamberts, who only has his best interests in mind. The patient’s adversarial posturing and complaints are insulting, convey a lack of respect, and are toxic to a doctor-patient relationship.
    If the patient is that unhappy with Dr. Lamberts’ follow up requirements, he is free to go to another doctor of his choosing. If I went to your art gallery and thought a painting was overpriced, I would shop elsewhere – I would NOT buy the painting begrudgingly while conveying anger towards you- insisting that I should be entitled to a cheaper price.

  19. I’ve read only two posts of yours. It is reasonable for you to ask to be assessed as a person in the context of everything you write… but you meet a person when you meet them… sometimes the overheard intemperate remark at a party is your first introduction, and sometimes it’s a particular blog post that is one’s first introduction.
    I’m responding only to what I’ve seen in those two posts.
    I appreciate that dealing with patients may not always be easy. I’m not a physician and I don’t see clients, and when I have had customers I have not found it an easy thing to manage… and all I was doing was selling art.
    You have no obligation to respond, but I am genuinely curious about whether you think that it is possible that some of the patients who you perceived as attacking you were actually responding to difficult economic decisions that they have little guidance in making.
    If you understood or agreed that it really wasn’t about you, would that change your response to this free floating anger that you picked up on?

  20. Mike: how many of my posts have you read? This was written on my blog as one post of four years of writing. You write as if you know what I normally write. This is not a normal post for me and should be taken into the context of the rest of my posts. You portray me as a person who attacks my patients, yet I really wrote as someone who felt attacked and insulted by a patient. I put a lot emotionally into my practice, so I do occasionally take things like that personally. It’s not my norm with patient. Read my blog and find out.
    Anon: No, I don’t self-prescribe. I don’t prescribe for my family – I make them see another doctor. We make our staff make appointments to be seen because we don’t want to give them bad care by doing it on the side. I don’t do it for my friends either. Why should I offer anyone bad care?

  21. To all you non-doctor writers: Go to your state’s medical board web site. Find the position statements of the board. Find the one on prescribing. Read the requirements for prescribing.
    Now answer how a doctor does this. He sees you. In person. Sometimes naked.
    He practices to a standard of care; a standard determined locally. Internet prescribing is expressly forbidden by my state medical board.
    Look at your doctor’s staff. Who pays them? If you want cheapercare, then go to a cheaper doctor. There is a federally subsidized clinic nearby. Their fees are generally lower or on a sliding scale.
    Then come see me in the ED when you are getting sicker instead of better. I must see you. Then don’t pay the bill. I am sure I can collect from someone else once in a while.
    Tomorrow I will see patients in our urgent care clinic. None will have or even need an appointment. They will come in because they want care or something only a physician or a PA can give them.
    It is not free. What was the question?

  22. Rob, You say:
    “Mike: You overestimate people. Many of the people who complain about the cost of care spend money poorly – that’s why they can’t afford care. It’s not a thought-out, deliberate choice. They just don’t like going to the doctor and don’t like paying for something they don’t like to do. They don’t see the value, but that does not mean there is no value. There is lots of value. I will draw my line and let them choose if they are going to see me.”
    I think you miss the point here. People are faced with a complex decision about resource allocation that they are ill-equipped to make. At $20 a visit it doesn’t matter much if they get it wrong, but at say $100 for a visit they know enough about the value of $100 to legitimately wonder (without being able to know the true answer) whether their overall well being is best advanced by spending $100 for a visit or on some other use that will also enhance their well being.
    Yes, as you say, people don’t really know, and of course they are not thinking about “qalys”, but they are trying to maximize some internal utility function, and an HSA based system is forcing them to try to make decisions that the vast majority of us are not equipped to make.
    I think you should have sympathy for that difficult choice, but instead you continue to insist that they are somehow belligerent and dislike doctors. It’s that attitude that I find so disturbing. Why do you personalize this? What’s with all the negative attributions toward your patients / customers?
    Of course you should try to help them understand the value of the service you provide, both as an objective health matter, and because it is in your business interest to do so. You’d probably be in a much better position to explain the value of the service you provide if you considered, rather than dismissed, the perspective of people who are being asked to make difficult resource allocation decisions that they have not previously had to make.
    You seem to have taken a few patients who have expressed hostility or resistance and taken this personally… “why don’t they see my value?” and “why don’t they trust me?” and “why are they so hostile to doctors?” and you seem to me to be unable to describe the situation from their perspective. Understanding the other side, the customer, the patient, is the first step in working with him/her, no?
    Don’t you think it is possible that you are faced with good people who are trying to resolve a difficult set of economic and health related decisions, some for the first time in their lives?
    Many people have NEVER had to ask the question of what a visit with a doctor is really worth to them… and HSAs are designed to make them ask that. It’s a new question and an important question and it puts people in a new position in relation to your services. It’s intended to do so. It is a system that is intended to make people question whether a given service is the best use of their money (even if the HSA money is limited to medical services.) And it’s hard for them. They may feel frustrated. They may feel angry to you. They may feel angry toward their employer.
    And how do you respond? By writing slightly angry and clearly annoyed tirades against your patients.
    Get angry at the HSA system if you like, or if you accept that putting more patient dollars on the line is the way the world will operate, then try to help your patients understand your value WITHOUT getting angry with them because they don’t yet see the world as you do, and are being forced for the first time to see your services not as a free good but as something they must evaluate (with few skills for doing so) against other services they also need.

  23. As a fellow PCP, I can assure you that your follow up requirements are more than reasonable. A patient with chronic stable medical problems requiring prescription medication should be seen at least once a year- and every 6 months may be more appropriate as significant changes in BP, cholesterol, blood sugars etc. can occur during that time period.
    Many of these comments supporting your patient’s position are way off base and are obviously from people who have no experience in the provision of health care. Are we supposed to trust the patient accurately reports his BP or weight? What if he has physical findings of a complication of his chronic disease that he may not be aware of? There is also alot of information that a good primary care physician can glean from a face to face encounter, much of which can be intuitive to an experienced doctor.
    And from a pure business perspective, how do people think doctors make money? We only get paid when the patient comes into the office. PCP’s operate under a very thin margin (specialists make about twice that of PCP’s). People seem to think physicians make so much money that they can and should provide complimentary services. If your patient doesn’t come in to the office, then exactly how are you to be reimbursed for the time you and your staff spend sending him a lab slip, pulling his chart, reviewing the results, contacting the patient regarding results, renewing his prescriptions and then documenting the whole process in his medical record? If you charged him an administrative fee for these services without seeing him, he probably would be even angrier than he already is by you “forcing” him to come in for an appointment.
    And what about the cost of malpractice insurance ($30,000 / year in NY) as you are making yourself liable for any medical complications he may have while in your care? If he did have a complication and you were sued, the fact that you had NOT forced the patient to follow up more frequently would surely be used against you by the plaintiff attorney.

  24. Expecting to be paid for the work one does is a “sense of entitlement?”

  25. This is why telemedicine is so important to the future of healthcare. Your sense of entitlement while perscribing care will hopefully be a thing of the past. It is an inconvenience to come to the provider, when the need can be met in other ways. The practice of delivering care needs to be patient centered. Engaging patients and developing new points of access will change delivery methods. Self management practices should be applauded although monitoring technology does need to catch up. Hope you are ready for the future Dr. Lambert.

  26. You overestimate people. Many of the people who complain about the cost of care spend money poorly – that’s why they can’t afford care. It’s not a thought-out, deliberate choice.

  27. Mike: You overestimate people. Many of the people who complain about the cost of care spend money poorly – that’s why they can’t afford care. It’s not a thought-out, deliberate choice. They just don’t like going to the doctor and don’t like paying for something they don’t like to do. They don’t see the value, but that does not mean there is no value. There is lots of value. I will draw my line and let them choose if they are going to see me.

  28. no offence to Rob, in his day I am sure he was a great poker and proder, but if guys will wait in line 2 hours, pay a $100 cover and pay $10 for water at a Club then the problem with healthcare is obviously the doctors. what we need is younger more attractive doctors. $80 for an office visit would be a steal if the right doctor was poking and prodding.

  29. My dentist has me on a 3 month recall. I’m a cash patient and I’ve considered whether this is really warranted.
    If I go back in and have slacked off on the self-care – brushing and flossing- I hear about it. So that 3 month appointment keeps me on the straight and narrow self-care program. If I slack off I’ll hear about it.

  30. Here’s a basic truth. Money, and financial security, also produce health and long life. Money has alternative uses that create pleasure and long life. The cost of our relationship to the entire health care system has to be considered in terms of alternative uses for those funds.
    You say “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,….”
    No, I think you are wrong to say the decision should be based on what is “medically right”. Rather it should be based on a larger equation that includes the total utility that the individual is seeking to maximize in the entirety of his or her life.
    They may be objecting because $80 or $120 for a visit is a chunk of change that actually has health significance at the margin. It has other valuable uses that can improve nutrition, increase a sense of security, and even impact longevity, particularly at the economic margins…. but arguably across the income scales.
    But while the value of spending $100 on a health care visit is unknown, I have to believe that the value is not entirely subjective. The fact that people hesitate tells us something objective, something that people understand about the alternative health producing and life optimizing uses of financial resources.
    I would tend to believe that people’s lack of willingness to pay suggests that on some level they sense that it is debatable whether that $100 best advances their health when spent on your services or on other uses. They have alternative life enhancing uses for that money, and uncertainty about how to optimize their own utility function or quality adjusted life years.

  31. Thanks Bev. I’d say that at least 50% of the visits that are just “routine follow-up” visits end up having something unexpected or significant that would not have been otherwise discussed. If someone comes it I will fish some to make sure there aren’t any things they wanted to discuss. I have found abdominal masses, atrial fibrillation, DVT’s, and diabetes simply by discussing things and examining appropriately. It’s called being a doctor.

  32. I am not a PCP so am not qualified to discuss frequency of visits. However, I just want to report that I am impressed that Dr. Lamberts actually performed a physical exam on a patient in for a routine visit for hypertension (the one with the cancer), rather than just taking his blood pressure!
    I will never forget a patient sent to our lab for pre-total hip replacement autologous donation, by our highest-volume orthopedist. The blood donation tech went through her checklist questions including infection and the patient showed her an open, draining sinus tract on her side. When I called the orthopedist, he was utterly shocked. Obviously he had never examined the patient. The surgery, of course, was cancelled since one cannot implant a foreign body in the presence of infection.
    Was finding the cancer fortuitous? Yes, but it was only found because Dr.Lamberts was following good medical practice, a “value” all too rare these days.

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  35. Bravo Margalit! It is NOT all economic. It’s just uncomfortable baring all (both figuratively and literally). I hate going to the doctor. Sometimes I even hate looking in the mirror (but my therapist is working on that one).
    Regarding AEK’s comment, I do think you are reading too much into this. The bottom line I have said several times is that disease follow-up requires a certain frequency of visit. I do my best not to bring patients back too often (I called in a prescription for a cold sore today – I don’t need to see a cold sore), but in the end, I am the one who decides since I write the prescription. Honest. I am reasonable. This post should demonstrate that fact.

  36. I think that defensive medicine plays a large role here. Remember, when sthg goes wrong, attorneys look through the medical history in retrospect what action could have prevented the bad outcome. And I have been burned by a patient who did not only not follow up, but had a significant change in symptoms in the meantime which he did not tell me about. The only solution is, at times, to recommend sthg and have the patient refuse to do it. Sounds idiotic and not helpful, but that’s where we are.

  37. I think we’re over complicating the issue. The simple fact is that people do not like going to doctors. They don’t like waiting forever in crowded little rooms, or having to take PTO, or getting undressed and sitting on a high table, or having blood drawn, or peeing in cups, or having a total stranger poking and prodding their most intimate body parts, and people don’t like talking about being obese, irresponsible, old, ailing and generally dying.
    That’s why a good doctor will always have to “force” patients to come in regularly. Most people will resent the “forcing”, but they do know that it’s necessary, just like they know they should quit smoking, go easy on the Big Macs and exercise.
    It’s just the human condition and that is why getting health care is never going be the same is hiring a plumber, if practiced correctly, and we all know that, so I think we should stop pretending otherwise.

  38. Continuing to play devil’s advocate:
    What evidence/argument underpins “reasonable frequency” of visits?
    Do you (and other Primary care docs) discuss the expected visit schedule with your patients when first assessing – e.g. for prevention only vs. f/u management of diagnosed conditions, such as HTN? And if so, do you use written patient “contracts” to formalize this understanding (could also be in the form of patient education documents/media).
    You refer to diagnosing cancer as an incidental finding during an exam for an apparent unrelated issue. While that’s fortuitous, how does that factor into your “reasonable frequency” rationale for scheduling visits?
    The “informed consumer” model makes demands of patients to “shop” instead of assuming a dependent patient role where trust in the physician is paramount. Perhaps this also factored into the unsatisfactory exchange.
    The use of “force” in the physician/patient relationship is unfortunate. If you ascertain that you are having to “force” patients to visit, perhaps it might be useful to do a root cause analysis of your practice policies and patient knowledge/perceptions/preferences to find out why and where there are misalignments so that you can address them to increase voluntary visit and self-management compliance.

  39. I think I shared in my post the fact that we did discuss medications and I even cut the cost of it. The perspective of a doctor “forcing” someone to come in for a prescription is the same as a cable company “forcing” you to pay a bill every month. They are giving a service that is of value (arguable, given TV programming), and so am I (writing a prescription medication), which they depend on me for. I am taking time, taking responsibility, and am saying the drug is appropriate in this setting. I cannot know that without seeing the patient at a reasonable frequency.
    The bottom line is that I wouldn’t do differently (in fact, I usually want to see people with these conditions every 6 months, and find that to be of value). This man can see another doctor if he doesn’t trust me to do what’s best.
    This post, of course, raises the question of where that line is drawn. We always need to be introspective in this way. We need not assume we are always right.
    I actually saw a man today in the office, whose words were (really): “Thank you for diagnosing that cancer. I wouldn’t have come in if you hadn’t made me come in to be seen [for his blood pressure].” He’d be dead if I didn’t “force” him to come in.

  40. AEK, Your comment is very thought provoking for a primary care physician. It is easy to remain focused on what we preceive as needed and valuable information and advice, and not see past the “medical” issues to see the important issues.

  41. “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?”
    Dr. Lamberts,
    This is really the crux of the matter. When there are no established standards, evidence based or otherwise, there can be huge differences in practice patterns depending on everything from local custom to the supply of doctors in an area to how money driven particular doctors may be. Under those circumstances, it’s easy to understand why patients might be skeptical about how often they need to come back especially if they are uninsured or their out-of-pocket financial exposure is comparatively high.
    By contrast, my own company pays for a physical every five years for someone in their 30’s but annually if you’re 55 or older. It’s a definitive standard and it inspires confidence on the part of employees that the intervals are appropriate.
    In my own case, I was seeing a urologist for a checkup every six months following a surgical procedure in 2004. After several years of clean checkups, I asked if I could safely stretch out the interval to once a year. He agreed that I could and I did so. That cut the cost for both me and my insurer in half. If doctors have evidence regarding the appropriate frequency of checkups, by all means, present it to the patient.

  42. Though you frame this case in terms of monetary value, from what you shared about the case in the previous post, I am inclined to think that the patient was objecting more to the visit from the perspective of successful self-management.
    You shared that he reported full medication compliance and monthly blood pressure measurement. Huzzahs!
    Diet, exercise, hazardous materials exposure and sources of significant stressors were not shared in the case. Were they assessed? If not, why not? If so, was the patient exercising successful management strategies?
    Beyond the out of pocket cost for your maintenance visit, this patient also likely incurred a cost of taking time off from work (>50% employers don’t reimburse for this and many will penalize workers even up to terminating them for using work time this way – another potential source of stress).
    To discuss this in terms of your schedule instead of patient ROI is maybe missing the point. Berating the patient for expressing his reluctance isn’t necessarily a strategy which will encourage future contact and partnership with you.
    What exactly did the patient get out of his visit with you? Strategies to continue successful HTN management? Diet information? Stress reduction information? A referral to a soc. service agency which might help him with financial concerns? Exercise strategy info?
    In this case, it appears that you used your position as one of power and control instead of as a partner in health. Essentially you conveyed to the patient a threat: pay you for a visit or else (no scrip). Instead, you could have used his concern as the launching point for teaching effective self management strategies and building a stronger foundation of trust between you and the patient.
    Of course this opinion comes with a huge caveat: I am responding solely to what was shared and you may have addressed all of these issues.