(CBS) Americans get too much health care, doctors say

Posted by Kendall Harmon

At a time when many Americans say they're having trouble getting good health care, a new survey of doctors said just the opposite.

A poll of 627 primary care physicians showed that nearly half believe their patients in their medical practice are getting too much unnecessary care, prompting the survey's authors to call for reform of the industry.

The survey - published in the September 26 issue of the Archives of internal Medicine - showed that only 6 percent of doctors felt patients received too little care.

Read it all.

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62 Comments
Posted September 28, 2011 at 5:55 am [Printer Friendly] [Print w/ comments]



1. Dan Crawford wrote:

What nonsense. The doctors ought to be happy - they can purchase bigger and better homes, buy boats and take longer vacations. Of course, the news that doctors think Americans can too much health care will no doubt surprise those millions among us who no access to health care. Ah, but why disturb complacency? No doubt we should applaud those who applauded the advice that the young man who couldn’t afford health insurance should busy himself about dying.

September 28, 11:42 am | [comment link]
2. Archer_of_the_Forest wrote:

No 1. I am forced to agree. I mean, this quote was a winner:

A poll of 627 primary care physicians showed that nearly half believe their patients in their medical practice are getting too much unnecessary care, prompting the survey’s authors to call for reform of the industry.

And the doctors never bothered to turn the patients away and say, “Go home, you don’t need care.”?

September 28, 12:36 pm | [comment link]
3. Cennydd13 wrote:

Far too often, migrant families have no option except to turn to hospital emergency rooms for even routine medical care because they can’t afford anything else, so what do these doctors expect, for pete’s sake?  While I’m willing to begrudge them a decent standard of living, I do expect them to show some compassion for those who don’t, and if this means spending some extra hours taking care of people who have no other choice, then so be it.

September 28, 1:16 pm | [comment link]
4. Clueless wrote:

And the doctors never bothered to turn the patients away and say, “Go home, you don’t need care.”?

Nobody comes in saying “I feel great, I’m just here to use up resources”.  Instead they come in with nonspecific symptoms such as muscle aches, or forgetfulness, or sleeplessness or headaches or generalized pain or the like.

So, before you can say “go home, you don’t need care” you need to take a detailed history and examine them. It would also be appropriate to check some stuff - thyroid, B12 for fatigue, etc.  At that point you can indeed reassure the patient and say “You have nonspecific fatigue with no clinical evidence of sleep apnea” or whatever.  However most patients are not happy with that outcome.  They do not wish to hear that it is normal to be 70 years old and to not be able to do the things that you could do when you were 30 years old.  They want and expect that “something will be done”.  They get mad if 5 years and 40 pounds later somebody finds that they now have mild sleep apnea, and they will blame their malaise and weight gain on your failure to “make the diagnosis” previously.  “He just didn’t care.  He didn’t even try to find out what was wrong. He was just interested in money, and getting me out as quick as possible”.

The solution, of course, is to stop paying for anything but catastrophic care (anything that requires more than 10,000 dollars.  That would stop the stress tests for nonspecific chest pain, the sleep study for nonspecific fatigue and all the rest of it. 

Stopping the abuse of the insurance/medicare/medicaid system by the worried well would free up money for the UNINSURED to actually have catastrophic care. 

So you have to
If there is nothing wrong with them, but the patient feels that there is something, i

September 28, 1:17 pm | [comment link]
5. Teatime2 wrote:

Yes, I think they need to qualify that with “the well-off and well-insured often get too much healthcare.”  The rest of us? Not so much, particularly if you have low-paying insurance or need a payment plan for the copays. Then, they’re not in any hurry to schedule you for tests.

You have to laugh—when a congressman gets a bit dizzy or has the flu, it makes the news because he’s being admitted to hospital. The rest of us take an over-the-counter med and go to bed. We have our surgeries, procedures, and babies and we’re discharged in a matter of hours.

September 28, 1:18 pm | [comment link]
6. Clueless wrote:

What we have is overutilization of medical care by the well insured, and inadequate access to medical care by the uninsured.  This is made worse by the fact that physicians can be sued if they fail to order a stress test for the minor, nonspecific chest pain in an otherwise normal 50 year old and that 50 year old several years later has a heart attack.  If one can lose ones home, savings and feel tremendous guilt for “not getting a test” one tends to get the test.  It makes everybody sleep better at night.

September 28, 1:40 pm | [comment link]
7. Clueless wrote:

What one needs is the ability to say “Well, I hear your complaint that your headaches occur daily, are excruciating and have made you miss work 5 times in the past month.  However, your neurological examination is completely normal, and your history is most consistent with migraines that have been made worse by the fact that you have been taking Ibuprofen and Percocet every 6 hours for the past six weeks.  I think you have analgesic/opiate overuse headaches, and I want you to stop taking the pain medications, and we will give you something that will work hopefully, a little better.  If you do these things, I think the headaches will be a little better in 2 weeks and much better in 3 months.  I think that the chance that you have a tumor is only about 5%.  Would you like to follow my advice and get an MRI in 3 months if your headaches haven’t resolved, or would you like to pay 2000 out of pocket for an MRI now?  If everybody had to pay 2000 dollars every time they wanted to have their minds set at ease they would learn to tolerate a lot more uncertainty.  Certainly physicians learn to tolerate uncertainty.  Most patients who have no insurance tell me “I trust you doc. Let’s do that”.  Most people who have insurance tell me “What are you talking about? Obviously if there is a five percent chance of a tumor, I want to know now”.

September 28, 2:05 pm | [comment link]
8. Catholic Mom wrote:

Of course, part of this is because what should be minor health care gets turned into major health care (at least in terms of billing) by the doctors and hospitals themselves.

I’m very allergice to wasp stings.  We have wasps here that make nests underground and they become very aggressive in August and September.  One late evening this August I was out walking my dogs on the sidewalk and apparently there was a nest under the sidewalk (someone told me this later) with an opening between the cracks and a wasp flew out and stung me as I walked by.  I immediatly went home and took a benadryl and iced it, etc.  Usually the affected part blows up like a balloon but I’m OK otherwise, but in this case about 2 hours afterwards my hands started turning red with red streaks running up my arms.  I happened to be alone as my husband and kids were overseas and I didn’t think it was good to ignore so at 12 pm I went to the emergency room.  The treatment consisted of this—they gave me a steroid pill and watched me for three hours (I sat there and read the paper) and then I went home.  The bill was $1,000.  Yes—that’s one thousand dollars.  (Of course I have insurance and of course the insurance didn’t pay this amount, but this is what they would have tried to get out of me if I *hadn’t* had insurance).  And they wouldn’t give me another pill to keep at home in case it happened again. 

As it happened I saw another doctor who is a friend of mine for something minor the next week and I told him the story and he immediately wrote me a prescription for a couple of these pills to keep on hand.  The next week we were in Cape Cod and I took a pill along just to be on the safe side.  I was riding my bike along a path in the woods and another wasp flew out and stung me!!  (Bear in mind I usually only get stung about once every five years so I absolutely could not believe this was happening again.)  Went directly back to the cabin, took the steroid pill, and the next day you could hardly even see where the wasp bit me.  Out of pocket cost to me—$3.

September 28, 5:28 pm | [comment link]
9. Clueless wrote:

The problem is that medicaid pays less than cost, medicare pays less than cost, the uninsured pays less than cost, and therefore insurance needs to pay for everybody. 

Furthermore it is considered “felony medicare fraud” to let the uninsured person have a break (medicaid/medicare is supposed to get the lowest price, and if you write off charges, then that lowest price should be zero).  Thus, if a hospital accepts medicare (and they are legally required to do so to be accredited) then it must insist on billing the uninsured the maximum rate.  Medicare pays a percentage of the hospital’s “usual and customary charge”.  All insurance is as a percentage of medicare.  Thus if the cost of babysitting you was 120 dollars, the hospital is forced to say that its “usual and customary charge is 1000 dollars”. Thanks to prenegotiated “discounts” medicaid would pay 50 dollars, medicare would pay 100 dollars, insurance would pay 150 dollars, picking up the tab for the medicaid/medicare/no pay group.  The problem is those who have no insurance or medicare/medicaid.  They are the ONLY ones who pay the “usual and customary charge”.  HOWEVER, if the hospital tells them “just pay what medicare/medicaid pays” or “never mind, we wont charge you”, this is considered “medicare fraud”.  The US government has a large group of people looking over hospital bills just for occasions such as yours.  If a hospital fails to bill the full amount to the uninsured person (most of whom won’t pay anyway, but who must under the law be sent to collections as a “good faith effort”) then the amount (zero if it is written off before collections) becomes what Medicare should be paying.  If the reviewers review 100 charts and find 2 occasions where the uninsured person paid less than medicare, it will demand that 2% of all the hospitals revenues, together with a fine for “medicare fraud and abuse” be paid.

Hospital margins are only 3% (Mcdonalds runs 20-40%) and more than 30% of rural and city hospitals have gone out of business in the past 10 years. 

Again, the solution would be to use urgent cares (much cheaper) and to have your primary care physician to write you a script for steroids and an epipen.  The ER should be for folks at risk for anaphylactic shock.  Again, if you didn’t have insurance which paid for most of the bill, you would not have gone to the ER, would you?  Neither would folks with medicare have gone to the ER if they had to pay the full amount.  Nor would you have waited until midnight to do something about the problem.

The even better solution, of course would be to get government out of medicine entirely.

September 28, 5:50 pm | [comment link]
10. Clueless wrote:

Again, the problem was overuse of resources by the worried, but well insured (Catholic Mom).  In third world countries, where the government does not interfere with medicine, you can buy steroids over the counter at the local convenience store, along with your tamales and a pair of sandals.

September 28, 5:54 pm | [comment link]
11. Catholic Mom wrote:

I don’t think you understand.  I was bitten on the ankle but my HANDS were turning red and red streaks were running up my arms.  I was already in excruciating pain and my leg had swollen up to the point that I couldn’t get my shoes on.  I had to take my wedding ring off because my hands were swelling so badly that they would have had to cut it off.  I absolutely needed treatment and I needed it then.  There is no “emergency care” center I can go.  The only place I can go is the emergency room.  They were not “babysitting me.”  They were covering their butts (and practicing good medicine) by making sure that I didn’t go into anaphylactic shock in the parking lot.  After three hours the streaks on my arms started to fade and it was clear I wasn’t going to get any worse.  My point was just that they billed $1,000 for a single pill and for popping in every 45 minutes and saying “feeling OK?”  I understand the insane billing structure in the U.S.  I’m just pointing it out.

But the really stupid part was that they did not give me any way from preventing this from happening again.    Taking a shot of epiniphrene can have its own risks and clearly I responded well to an oral steroid.    They should have given me a prescription for this but they refused to do so.    Thus an emergency room in Cape Cod could have made a few $$$ two weeks later but thankfully a more rational doctor did me a favor although it was totally not in his purview to do so.  What’s wrong with this picture??

September 28, 6:04 pm | [comment link]
12. robroy wrote:

This is not controversial. Too much medical care absolutely can be hazardous to your health. I have five kids and the number of antibiotic prescriptions for all of them total less than 10 in all their life times.

Anti-biotics kill people. One of my first patients in medical school died a horrible death from an entity known as Steven-Johnson Syndrome. His skin basically bubbled off and he became one big festering wound. It was due to a very commonly prescribed antibiotic, Bactrim. Seeing that poor patients horrible demise makes an impression.

About 350,000 visits to ER’s yearly are attributable to Adverse Drug Events.

September 28, 6:59 pm | [comment link]
13. Clueless wrote:

“But the really stupid part was that they did not give me any way from preventing this from happening again.  Taking a shot of epiniphrene can have its own risks and clearly I responded well to an oral steroid.  They should have given me a prescription for this but they refused to do so.  Thus an emergency room in Cape Cod could have made a few $$$ two weeks later but thankfully a more rational doctor did me a favor although it was totally not in his purview to do so.  What’s wrong with this picture?? “

Again, the ER has no legal authority to practice “preventive care”. That is the job of your primary care physician. Thus, if you take too many hits of steroid and get aseptic necrosis of the femoral head, there will be somebody to sue.  If the ER doc gave you extra steroids for the “next time” he would be the one paying for the aseptic necrosis, (not to mention your pain and suffering if you were one of the tiny minority that that happened to) since any good lawyer would have pointed out that he had no business prescribing prophylactic steroids to somebody he had no long term therapeutic relationship with.  It is supposed to be the primary care physician who gives you steroids (and who monitors you for it, and says “Hmm.  You have taken 3 short courses of steroids already this year.  You are greatly increasing your risk of side effects.  What can we do to change this?).

Again, medicine is cheaper in third world countries where steroids can be bought over the counter.  The most that the kindly shopkeeper might say would be “MY.  You have been here a LOT to buy steroids, No?  Maybe you should see somebody?”  There it is your responsibility to read up on the dangers of the medications you use, and to use them responsibly.  By contrast, in the US it is anticipated that patients are too irresponsible and stupid to manage steroid hits the way folks in India manage to do so, and that is why not only can you not buy them over the counter, but you can sue the ER doc for “overprescribing dangerous medications”.  (That too btw is included in the 1000 price tag).

September 28, 7:12 pm | [comment link]
14. Catholic Mom wrote:

I don’t disagree with some of this but part of the issue is the degree to which pharmaceutical companies fight to keep things from being allowed to be sold OTC.  And doctors fight to keep you from being able to make simple medical decisions yourself.  You may recall that for years you couldn’t get a pair of reading glasses except by going to an optometrist.  The optometrists argued that this way you would be forced to have an eye exam and maybe many incidences of glaucoma would be diagnosed etc. etc.  But the upshot was that it would cost you at least $100 (not paid for by insurance) for a pair of reading glasses.  After a huge court fight they are now available in your local WalMart.  And apparently there is no great wave of undiagnosed glaucoma as a result.

September 28, 7:21 pm | [comment link]
15. Catholic Mom wrote:

A corollary is that if I lose a contact lens more than 12 months after I bought it, the eye doctor will require me to come back and have a complete eye exam before they will re-order it for me.  On the other hand, if I am careful and never lose one, I can go the rest of my life using the same pair and it is my discretion when/if to go back to the doctor.  So what I always do when I get a new prescription is buy two pairs.  If I lose one 13 months later, it is not going to cost me a $200 exam (not paid for by insurance—and why should they considering how unnecessary it is?) to order another lens.

September 28, 7:26 pm | [comment link]
16. Clueless wrote:

“Pharmaceutical companies fight to keep things from being allowed to be sold OTC.  And doctors fight to keep you from being able to make simple medical decisions yourself.”

Pharmaceutical companies would be happy to have over the counter drugs.  They would VASTLY increase their profits if everybody who wants Viagra could pick them up along with their condoms.  Pharma companies that do knock of Viagra in third world countries are much more profitable than our our own industry.  The problem is litigation.

When the guy with obvious heart disease takes viagra and drops dead, the lawyers will sue the doctor who prescribed it, if it were prescription only, but would sue the pharmaceutical companies if it were over the counter.  They allowed a “bad drug” on the market! Now this poor man with a wife and 6 children is dead!  Oh the tragedy. Those greedy bastards.

In India everybody will simply say “Shame!  He even knew he had heart disease, and had a heart attack and everything, and even so he went and used viagra!  He just had no self control!  He had a wife and children but wanted to have sex instead of working for their futures!  Animal, no!?  Chee!  Chee!  Shame!  ”  The prescription only simply ensures that folks who shouldn’t be taking the stuff are less likely to, just protecting industry from both the stupidity and irresponsibility of the end user, and the greed of the lawyers.

September 28, 7:34 pm | [comment link]
17. Clueless wrote:

“I lose a contact lens more than 12 months after I bought it, the eye doctor will require me to come back and have a complete eye exam before they will re-order it for me.  On the other hand, if I am careful and never lose one, I can go the rest of my life using the same pair and it is my discretion when/if to go back to the doctor.”

Well Duh.  If you develop glaucoma, your lawyer will stand up in court and say “the standard of care is that no prescription is made without a careful physical examination within a year.  But Dr. X wasn’t careful. No he couldn’t care less!  He just rubber stamped poor Mrs. Catholic’s prescription while laughing all the way to the bank!  And Ms Catholic, with her heavy dark glasses and her little white cane will be sitting next to the desk, weeping softly. 

You can’t have it both ways.  If you want cheap and easily available, you need to fix the litigation racket.  Right now, the malpractice system is America’s unofficial disability system.  Similarly the Insurance system with their high premiums is America’s means of taxing the working class (via inflated insurance premiums) to pay for both a legal system that bribes politicians and a political system that allows wealthy seniors to pay less than cost in exchange for votes.

September 28, 7:41 pm | [comment link]
18. Catholic Mom wrote:

If it’s an expensive drug and if the company has a patent on it, there is a huge motivation to remain prescription as insurance companies do not pay for OTC drugs.  Typically the drug companies petition the FDA to go OTC just as their patents are about to expire and they want to compete with generics that will be coming out.  Since they know doctors will be prescribing the generics they are going to take a big hit so switching to OTC will allow them to continue to make profits off the drug—particularly if they’ve built up a loyal following for it.  Of course, they have to drop the price.

September 28, 7:43 pm | [comment link]
19. Clueless wrote:

“If it’s an expensive drug and if the company has a patent on it, there is a huge motivation to remain prescription as insurance companies do not pay for OTC drugs. “

True.  However drug development is expensive (mostly due to litigation) and all drugs get stolen by china and india who make cheap knockoffs for their own countries within 2 years of a product’s coming out.  If a company plans to stay in business developing new drugs, (and most large companies have cut their research staff and now concentrate on doing bells and whistles on stuff they already make) then they have to pay their bills.  That includes legal bills.  Pharmacuetical companies are significantly better capitalized than hospitals, but even so, several of our pharmaceutical companies have gone out of business in the US, and now simply make generics off shore for foreign use.

If you want the lottery legal system we have now, the price can be seen in your drug store.  If americans were willing to accept the legal system found in India, their pharmaceutical costs would drop significantly.

September 28, 7:54 pm | [comment link]
20. Catholic Mom wrote:

Your belief that all “excess care” is litigation driven is an unjustified assumption when it comes to care that a doctor or provider is paid handsomely for (as opposed to ordering a test that he has no financial interest in).  There is a much simpler and more obvious explanation.  Especially when the doctors are lobbying to get laws passed to *require* you to get “care” that you don’t actually want.  In my state you can’t fill an *eyeglass* prescription at your local eyeglass store if it’s more than x years old (I think two).  So if you break your glasses you have to go back and get a new eye exam.  This is a law which the eye doctors lobbied to get.  It drums up an enormous amount of totally unneeded business for them.  Stepped on your glasses?  Too bad.  You’ll have to pay ransom to get another pair.

September 28, 7:55 pm | [comment link]
21. Catholic Mom wrote:

How do you account for the fact that prescription drugs are generally so much cheaper in Canada?

September 28, 7:57 pm | [comment link]
22. Clueless wrote:

“Several of our pharmaceutical companies have gone out of business in the US, and now simply make generics off shore for foreign use.”

You may have noticed that it is now very difficult to get many types of chemotherapy, certain cardiac and seizure medications etc.  Our pharmacy says that US pharmaceutical companies have been dropping a product line about 1-2x/WEEK for the past six months. 

This isn’t because they are greedy and don’t want to sell drugs (whether prescription or OTC).  It is because that while prices are high, costs are higher, and it is becoming cost ineffective to supply medications to the US market.  That is going to seriously disrupt patient care very, very soon.

September 28, 7:59 pm | [comment link]
23. Clueless wrote:

“How do you account for the fact that prescription drugs are generally so much cheaper in Canada? “

Canada does not have TV ads every 15 minutes saying “Have you been injured by taking Lipitor?  Call NOW. We have trained personell waiting”.  There is a price tag for litigation.  Americans prefer to pay that price tag, rather than to simply give up the dream of winning the malpractice lottery and retiring.

September 28, 8:01 pm | [comment link]
24. Catholic Mom wrote:

I don’t read that pharmaceutical companies are going out of business in the U.S.  I understand that they are one of the most successfull sectors in the whole economy.  For example, I just read:

  During the past decade, drug firms’ profits represented an 18.5 percent return on revenue or 5.6 times the median return (3.3 percent) of Fortune 500 companies.
The five most highly paid drug company executives pocketed more than $183 million in compensation in 2010, with the top 25 pharmaceutical execs averaging nearly $6 million in annual compensation. 

Re Canada I understand that:  1) the Canadian government limits what the pharmaceutical companies can charge for a drug 2) there is a national medical system that negotiates with pharmaceutical companies as to which drugs will be put in its formulary.  This is a huge market that companies will compete to get the business of.

September 28, 8:06 pm | [comment link]
25. Clueless wrote:

Your belief that all “excess care” is litigation driven is an unjustified assumption when it comes to care that a doctor or provider is paid handsomely for (as opposed to ordering a test that he has no financial interest in).”

When I was in private practice, I was paid much less per hour than my mechanic, and only five dollars more an hour than the hairdressor at the cuttery. 

BTW physicians are NOT paid for ordering MRIs or lab tests etc.  At least not unless they own their own MRI scanner, which few physicans do, and which (I think) may be illegal under the most recent laws.  Actual costs from law suits are relatively small in the overall figure, however defensive costs are large.  If you can get sued for not getting a test, or for not insisting that the patient come in, then you are going to have the patient come in. 

If the patient were allowed to sign a waiver agreeing to binding arbitration (as your stock broker and lawyer can do) then it makes sense to consider other ways of practicing medicine.  As long as America expects perfect outcomes and feels that they have the right to sue for every bad outcome, America will pay a premium for this expectation. 

“So if you break your glasses you have to go back and get a new eye exam.  This is a law which the eye doctors lobbied to get.  It drums up an enormous amount of totally unneeded business for them.  Stepped on your glasses?  Too bad.  You’ll have to pay ransom to get another pair. “

Eye doctors are mostly optometrists and 90% of these are owned by companies who also make glasses. If the prescription wear does not “fit” and patients get headaches or crash their cars because they have the wrong prescription, then the company gets sued.  (So can the optometrist/opthalmologist if they failed to perform “due diligence” and provide an up to date prescription).  There have been plenty of lawsuits against eye doctors for “bad prescriptions” leading to car accidents or other tragedies.  This is the reason that the legal standard of care is an annual eye examination.  If a patient wishes to use the same pair of glasses for the next fifty years, that is the patient’s look out.  If he crashes his car, it is his fault.

Again, the problem is lawsuit happy americans.  You can’t have it both ways).

September 28, 8:17 pm | [comment link]
26. Clueless wrote:

http://www.nytimes.com/2011/03/07/business/07drug.html?pagewanted=all

“This is a sobering reversal for an industry that just a few years ago was the world’s most profitable business sector but is now under pressure to reinvent itself and shed its dependence on blockbuster drugs. And it casts a spotlight on the problems drug companies now face: a drought of big drug breakthroughs and research discoveries; pressure from insurers and the government to hold down prices; regulatory vigilance and government investigations; and thousands of layoffs in research and development.

Morgan Stanley recently downgraded the entire group of multinational pharmaceutical companies based in Europe — AstraZeneca, Bayer, GlaxoSmithKline, Novartis, Novo Nordisk and Roche — in a report titled “An Avalanche of Risk? Downgrading to Cautious.” The analysts wrote, “The operating environment for pharma is worsening rapidly.

The same concerns apply to drug giants in the United States. They are all struggling with research failures as they scramble to replace their cash cows, like Pfizer’s multimillion-dollar gamble on a replacement for the cholesterol-lowering drug Lipitor, which failed miserably in clinical trials. Drug companies cut 53,000 jobs last year and 61,000 in 2009, far more than most other sectors, according to the outplacement company Challenger, Gray & Christmas.

“This is panic time, this is truly panic time for the industry,” said Kenneth I. Kaitin, director of the Center for the Study of Drug Development at Tufts University in Medford, Mass. “I don’t think there’s a company out there that doesn’t realize they don’t have enough products in the pipeline or the portfolio, don’t have enough revenue to sustain their research and development.”

September 28, 8:20 pm | [comment link]
27. Catholic Mom wrote:

BTW, let me tell you another example of my experience that U.S. doctors are not bitterly decrying “excess care.”  I actually did try to call my primary care doctor re: getting a prescription for the steroids.  (By “primary care” I mean a regular internist since I’m not required to have a “primary care” doctor by my insurance company.) 

Now, I am incredibly healthy (when not being stung by wasps) and I almost never go to the doctor except for annual checkups.  I go to my ob/gyn once a year for an exam (which includes blood pressure, etc.) I get a mammogram, etc. every year, but I only visit the internist when I’m actually sick, which is never. 

So I call up her office and they say that of course she isn’t going to prescribe this over the phone (which clueless will no doubt will say is litigation driven but I will point out that she gets paid nothing to call in the prescription and more than $100 for an office visit) and I say “fine I’ll come in”  (a waste of time for me and money down the drain for the insurance company but that’s the way the racket is set up) and the receptionist says “well, you are a new patient and we’re not taking new patients for three months.”  And I said “I have been going to Dr. X for 15 years” and the receptionist says “if you haven’t been in to see the doctor for three years we consider you a new patient.” 

So I need to go to the doctor for a totally unnecessary “check up” at least every three years or she won’t see me when I’m sick! (Or in this case not even sick but just need somebody to call in a prescription for me, for which she only needs to talk to me for about sixty seconds. )  Please explain how this one is litigation driven. smile

So the hospital charged $1,000 for the first pill and my doctor wanted at least $100 to call in the second pill (if she even would do it, which in this case she wouldn’t) and it’s only because I have a friend who is a doctor that I got the pill at all, which then saved me (and my insurance company) another $1k two weeks later.  Brilliant system.  And I recognize the role of litigation but it’s far far from the only factor in this insanity.

September 28, 8:29 pm | [comment link]
28. Clueless wrote:

Please see above.  You need to have a therapeutic relationship with a physician if he/she is to prescribe medications for you.  Suppose that in the three years since you had last been seen, you had developed diabetes, or had become immunocompromized (cancer, HIV etc.). Then prescribing the steroids would have placed you in physical danger and her in legal danger.  This again is why there is a LEGAL standard of annual check ups (for the doctor, the patient is not held to any legal standard).  (I’m surprised that she said that three years was okay, in most places you are expected to be seen within one year (or pretty close thereto). 

I understand that you feel that the doctor should, for free, (based on the fact that three years ago you paid him a 10 dollar copayment and insurance paid him 50 bucks for an annual physical) prescribe any and all medications you desire over the phone on your say so. 
However, from a legal point of view, the doctor would need to spend 20 minutes on the phone retaking and updating your history, even if he trusted you to be honest with him, and to be truthful when you tell him that you are entirely healthy and have a normal physical examination.  The doctor then needs to dictate it all into the chart (paying a medical transcriptionist for the service), and then maintain the medical records for a minimum of 7 years (again the legal standard).  The transcription costs alone would be some 15 dollars. The legal costs if you had forgotten about the fungal lung abscess 2 years previously, might be astronomical.  If he does this for you, who are healthy, he will be expected to do it for Mr. Smith who has only mild diabetes, and well controlled heart disease. If he does it for Mr. Smith then he needs to do it for Mrs. White who is as sick as a dog, but has trouble getting transportation to doctors offices.  If he “discriminates” by letting his healthy (read private insurance) patients have prescriptions over the phone while insisting that his sick (read medicaid/medicare) patients come in for a visit, then he is DISCRIMINATING ON THE BASIS OF INSURANCE which is MEDICARE FRAUD.

What other services have you been able to obtain for free, based on payment for a different problem 3 years previously?  Will your tax acountant do your taxes for free if you just say “nothing has changed from last year - so this should only take you “60 seconds”?

 


So I need to go to the doctor for a totally unnecessary “check up” at least every three years or she won’t see me when I’m sick! (Or in this case not even sick but just need somebody to call in a prescription for me, for which she only needs to talk to me for about sixty seconds. )  Please explain how this one is litigation driven.

September 28, 8:49 pm | [comment link]
29. Catholic Mom wrote:

No, you didn’t read carefully enough.  The problem was not that she would have called it in if she had seen my within three years.  She wouldn’t call it in regardless AND I was being punished for not having shown up for three years by being pushed to the end of the line as a “new patient” if I DID want to come in and see her.  In other words “come in to see me regularly whether you need to or not—whether you are getting checked up by another doctor or not—or when you are actually sick my receptionist will tell you that you are a “new patient” and I won’t see you for three months.”

September 28, 8:59 pm | [comment link]
30. Clueless wrote:

Lawyers have forced physicians to be “keepers of the medical record” (unlike places like Greece where there is no malpractice, and where patients are supposed to maintain their medical records and bring them to each doctor/specialist visit where they will be scrawled onto by whomever they see).  The physician is not paid for the legal service of being “keeper of the medical record” (and the medical record is mostly useful for the court).  Similarly the physician is not paid for his service as tax collector from the working classes, in order to support the uninsured.  However he is a useful whipping boy for those who wish to insist that everybody have access to medical care, but nobody’s taxes be raised to pay for it.

Because you did not update your medical record, you will take more time than if you had been recently seen.  The doctor however, does not have an unlimited supply of time.  Once I enter my clinic (at 8am, I work steadily through lunch until about 6 when I see my inpatients and read EEGs.  I usually have one bathroom break during which I grab coffee of less than 15 minutes around lunchtime.  I grab dinner before I see my inpatients.  There is a 3 month waiting list to get in to see me.  If there is an emergency (and there is most every day) then I stay late.  I never go home early.  I can’t.  However, while I am willing to stay late for emergencies, I do not stay late for irresponsible patients who have not seen me in 3 years but now have a new problem and figure that I “owe them” prompt and immediate care because after all I saw them 3 years ago.  They can stand in line with everybody else.  Everybody else is also calling my office and saying stuff like “he has missed so much work/school, he really needs to be seen ASAP, can’t she fit him in tomorrow?  I have the day off tomorrow and can bring him in around 2.  No. I can’t fit him in.  I’m sorry” 

There happens to be a doctor shortage.  That too has to do with medicare price controls.  If you want to be seen promptly and have somebody call in unlimited prescriptions, I suggest you find an internist or family physician who has a concierge practice. They will NOT accept your insurance. Instead you will pay an annual fee, however you will be able to get in within 24 hours to see a well rested physician who will be glad to call in prescriptions even if it means spending 30 minutes on the phone taking your history and dictating it into the chart.

September 28, 9:14 pm | [comment link]
31. Catholic Mom wrote:

Every single test or checkup I have is forwarded to this woman as my “primary care doctor.”  The emergency room forwarded its report to her.  She knows exactly why I went there and what they did for me.  My medical record is completely up-to-date.  I just don’t physically go in and see her when I have no need for her services.  By telling me that my status is set to “new patient” if I don’t show more regularly then I do (regardless of whether or not I need her services and regardless of the fact that I am having all recommended checkups by other doctors every year) she is doing exactly what other businesses do when they say “if you are not generating business for us regularly than you are not a favored client and you go to the end of the line when you need me.”  I do not see American doctors complaining of “excess care.”  I see them creating a system that generates excess and duplicate care.  As long as that is how they are paid, that would be what any economic model would predict.

September 28, 9:34 pm | [comment link]
32. Clueless wrote:

Be that as it may, all of these tests take time to integrate.  A ‘simple decision” as to whether or not steroids are safe, requires reviewing and integrating all the above.

The legal consequences for failing to do this are high (as are the physical consequences of missing that fungal abscess).

Why do you think that physicians should do all that work for free if you occasionally see them every few years?  Insurance does not pay for her to either review or maintain the chart, nor to prescribe over the phone.  Why do you think you are entitled to free care?  That is what you are demanding.  I have a relationship with you. Therefore take care of all my needs over the phone for free for the next several years, and trust me to be truthful with you. 

What other professionals do you expect this of?  I frankly don’t think that the standard of care of 1 year is that unreasonable. No lawyer would see you for 1 hour for 100 dollars and then do unlimited phone calls for the next 3 years.  You wouldn’t expect it of him.  Most physicians will do this for you for one year however.  After that you need to come in. This allows the physician to review and update the chart and get paid for it.  If you don’t like it, go concierge, or go to the urgent care.

September 28, 9:45 pm | [comment link]
33. Clueless wrote:

” I do not see American doctors complaining of “excess care.”  I see them creating a system that generates excess and duplicate care.”

Concierge care would fix that.  It usually includes unlimited phone calls/emails.  However most concierge practices charge about 300-500 dollars annually.  Most patients are addicted to the idea of the 10 dollar copayment.  Their insurance pays for a good deal more than 300-500 dollars, but as long as the patient just pays 10 bucks a visit he prefers this even if it limits phone/email interactions and increases the total cost of care.

September 28, 9:49 pm | [comment link]
34. Catholic Mom wrote:

You’re not responding to the point.  My complaint was not that the doctor would not prescribe over the phone.  I said that twice.  My complaint was that she has set up a system in which you have to see her for no reason at all at least every three years if you want to SEE her (not talk to her on the phone) when you are sick.  Otherwise she tells you she can only see the people that do business with her more often!

September 28, 9:55 pm | [comment link]
35. Clueless wrote:

And it is not physicians who created this system. It is the US government in order to buy votes from folks who have access to insurance and from the elderly. 

The US government pays the AMA to pretend to represent physicians (they only represent 17% - mostly folks in academic medicine) by paying them royalties on the DRG system which is what funds the AMA.  Then the US government pretends that physicians are lobbying to preserve medicare. 

Every physician I know HATES medicare and medicaid, and is angry at the dysfunctional system that has been forced down our throats by government who tells everybody that this is what we want. We would much prefer to set our own rates, give breaks to those whom we know can’t afford it, and to have patients sign waivers submitting to binding arbitration in case of bad outcomes (which every other profession is permitted to do, but which we are not permitted to do).  We would also prefer to go back to the apprentice system that cost nothing, and worked well before the government closed all medical schools other than those attached to universitites, and insisted that every physician be licensed, and regulated and graduate 150,000 in debt.

September 28, 9:56 pm | [comment link]
36. Clueless wrote:

” My complaint was that she has set up a system in which you have to see her for no reason at all at least every three years if you want to SEE her (not talk to her on the phone) when you are sick. “

Read my posts.  The annual physical (in this case q 3years) is the mechanism by which physicians get paid for the phone calls, form filling duties, legal requirements updating your chart etc.  All that costs money.  All that takes time.  There are no “free slots” in any physicians day, unless there is a last minute cancellation.  If you don’t want to do the annual physical then get a concierge physician.  They will do the entire business over the phone.

September 28, 10:02 pm | [comment link]
37. Catholic Mom wrote:

So I have to have an annual physical at my gynecologist every year (my primary care doctor is not going to do a pap test) and then another one by my primary care doctor in order for her to be willing to see me when I’m sick—notwithstanding that she is actually being paid to see me when I’m sick.  Yet doctors are complaining because Americans are getting “excess care”??  BTW, I’m not my insurance company would even pay for this.  I think what I’m supposed to do (or what my doctor’s policy would seem to suggest I do) is just make up a minor complaint once a year and come in for that.  But isn’t this just what you are arguing is the problem with Americans?

September 28, 10:08 pm | [comment link]
38. Clueless wrote:

If you are going to take more time than a routine follow up, you will need to take up a new patient slot.  My next new patient slot is in late December.  I imagine that that is when your doctor’s next new patient slot is.  If you get squeezed into a follow up slot, your doctor will be overbooking, her other patients will have to wait while she reviews your data, and they will be upset.  In point of fact there is always some waiting in doctors officers anyway, becasue folks who come in supposedly for a routine follow up, often say (usually near the end) “oh by the way, I also am worried about this chestpain, blood in my urine etc.”  And some folks are just plain sick and take more time.  However you clearly are NOT sick.  You just needed extra time to update your chart in order to determine the safely of corticosteroids, since you had not been seen in three years.  Since you were NOT sick and hadn’t been seen for several years, it is ENTIRELY appropriate that you go to the end of the line, instead of forcing everybody else to wait on you, making clinic even later than it would otherwise be.

September 28, 10:11 pm | [comment link]
39. Catholic Mom wrote:

And if I get stung by a wasp within that three month window (as I actually did) then I go to another emergency room and get another $1,000 pill??

September 28, 10:15 pm | [comment link]
40. Clueless wrote:

Well I would find a family physician who is willing to do a pap smear.  I don’t see a gynecologist for my pap smear, I see my family physician.  If you have a history of uterine cancer or some other significant gynecological illness that requires a gynecologist then yes, apparently you need a specialist.  Otherwise, I would dispense with the specialist and maintain a family physician.

If you are seeing an internist because you have a bunch of other medical problems that a family practice doc can’t handle, then yes, again you are seeing a specialist because you have other medical problems. 

If you are actually “healthy” then I don’t understand why you are maintaining both an internist and a gynecologist.  I don’t. My mother has more than one doctor, but then she is 84 and has had breast cancer, a pacemaker and a bunch of other things wrong with her.  The only people I know who maintain multiple physicians require specialist attention.  Me, I’m so busy, I do my best to get my patients back to their family physicians once they are stable from a neurological point of view. If they are seizure free and just need meds, I prefer that the family docs prescribe them.  I don’t want to see folks who don’t need me, I have enough trouble finding time for the folks who do.  Most gynecologists I know are drowning in work and would be glad to let family physicians do the annual pap smear in routine followups. 

Again, excessive utilization of medical care.  Why do you feel that you need both a gynecologist and an internist if you are, as you say, “healthy”?

September 28, 10:23 pm | [comment link]
41. Clueless wrote:

“And if I get stung by a wasp within that three month window (as I actually did) then I go to another emergency room and get another $1,000 pill?? “

Concierge care begins to look cheap, doesn’t it? So does seeing a doctor once a year for the “annual physical”.  But the cheapest of all would be to revise the malpractice system, so that pharma companies would be willing to make steroids over the counter, as they are in other countries.

September 28, 10:31 pm | [comment link]
42. Catholic Mom wrote:

I don’t want to “maintain” anybody!!  Does anybody “maintain” me??  I’m a consultant.  When people need my services, they pay me.  I don’t require that they purchase unnecessary services in order to “maintain” me.  I have never heard of a primary care doctor doing a pap smear.  When I see her (which is rarely) she checks her chart and nods approvingly that I have been seeing my gynecologist every year.  She never says “I could do that for you.”  Every woman I know sees their gynecologist for their pap smear and general gynecological check up.  I have had numerous insurance companies over the years and none of them has ever suggested I do otherwise.  Even the ones that require referrals (e.g. Aetna) let every woman pick a primary care doctor AND a gynecologist and they can see the gynecologist once a year without a referral.  So apparently this is standard practice.

September 28, 11:17 pm | [comment link]
43. Teatime2 wrote:

Steroids over the counter? Seriously? Surely you realize that chronic steroid use becomes, as my internist puts it, just like another disease to manage. Weight gain, osteoporosis, diabetes, cataracts, mood changes, and other nasty side effects ensue.

Prednisone is a necessary evil in my case but I’m still only prescribed it when I’m in a bad way. I’m currently tapering from a 70 mg. dose and can’t wait to get off the stuff. I can’t imagine making steroids available “over the counter.” There would be plenty of morons who would decide that the anti-inflammatory and energy-boosting effects were worth the risks. And then we’d have even more obese people with diabetes and other chronic steroid-related issues toddling around.

You can purchase antibiotics over-the-counter in other countries, too. Is it really a good idea for people to be taking them on their own whenever they have a cold or the flu? Could that be why we have more antibiotic-resistant TB and other bugs on the Border where I used to live? People went to Mexico to buy antibiotics all of the time.

We need balance and common sense.  When someone like CM has a severe, known allergy, she needs to be provided with patient education and a kit containing the meds she needs in case of an emergency. But we don’t need to open the candy store to everyone. And I do agree that internists can and should handle routine care and screenings, such as Pap smears and breast exams. Mine does. She is also my care coordinator, keeping in touch with all of my specialists and discussing all of the issues and options with me.

But it’s taken me a long time to find a good internist who is willing to do that. Most don’t want to take the time or take on the challenge because it’s time and labor-intensive without providing adequate compensation. I don’t blame them. There’s no incentive to educate people and help them to manage their health and care. It’s more lucrative and takes less time to cater to the needs of the well-insured.

The American system is horrible about trying to keep people well, probably because of its for-profit, big business emphasis.

September 28, 11:37 pm | [comment link]
44. Country Doc wrote:

I have practiced for 44 years in the most poverty stricken and lowest physician to patient ratio area of the nation. I can say the study is true.  there is too much medical care given in our country.  In our area there is mostly medicaid and no pay patients.  Half the appointments given are not kept and half who do come did not fill the perscriptions you gave them last visit.  There is more medical care thant they want.  They can go to the emergency department for free and can’t be turned away.  20% of perscriptions written for the children seen there are not filled.  Also, half drop out of school so there is more education available than they want.
    I believe the about 35% of the labl, xrays, and procedures I order or patints sent to the hospitals for admission are not necessary, but if one family member wants it we do it to the max so some schister lawyer won’t be able to ask us in court why we didn’t do it.
    The answer.  None.  The administration has said that there will be no tort reform allowed, so we will just have to cover ouselves with a flood of tests, etc.  They have also said they want to discontinue the health savings accounts which has been proven to cut costs.  So I have no solution other than to retire and pay my taxes.

September 28, 11:50 pm | [comment link]
45. Sarah wrote:

RE: “I have never heard of a primary care doctor doing a pap smear.”

My primary does my pap smear.  I don’t see a gynecologist.

My goal is to get a physical once a year—maybe every year and a half—with my family physician.  I had thought everybody knew to get an annual physical [or thereabouts—maybe every two years if things are motoring along okay].

Last time, I got pretty much everything—the pap, he checked my skin for anything that looked abnormal, did my breast exam, and then I went and got my tetanus shot.  Had my blood drawn and he checked the results and called me with the news.

I agree that Americans—at least the ones who don’t have to pay much—get way too much health care.  There’s a small percentage that get too little.

Oh well—we’re long long long past any of this working out at this point; Central Planning is hoping to manage my “health care” for me, and naturally I don’t want that one bit.  My main goal is to just try to stay healthy as long as I can—do the things that are shown to be preventative of the vast majority of issues: no smoking, keep weight down, lots of exercise, plenty of fruits and vegetables, and my sunshine-in-a-little-green-pill, plus do my best on the preventive care with my family doctor and try to stay as far away from Government Care as possible until I’m forced into it.  I may “go bare” once the State has accomplished what it wants with adding everybody “for free”, but we’ll see.

September 29, 12:26 am | [comment link]
46. Sarah wrote:

In reading through this thread I am struck by the very large gap between those who know the rules under which healthcare labors and under which physicians are required to work and others.

All of the rules, of course, add to the cost.

RE: “(Of course I have insurance and of course the insurance didn’t pay this amount, but this is what they would have tried to get out of me if I *hadn’t* had insurance).”

Yes—and that money—which the insurance doesn’t pay under a contract based on quantity—is what is supposed to cover all that “free healthcare” that the emergency room and hospital are ladling out to the Medicaid and now Medicare patients and walk-ins who will Never Ever Pay anything.  The privately insured and the cash-pay pay the premium costs and that’s in order to float the rest of the country which is now approaching . . . anybody know?  35-40% of the population?

RE: “A corollary is that if I lose a contact lens more than 12 months after I bought it, the eye doctor will require me to come back and have a complete eye exam before they will re-order it for me.”

Physicians are REQUIRED to see patients.  If a patient gets the new contact lens at 13 months without seeing the eye doctor and the patient actually has a raging eye infection and pops that little contact back in and manages to lose her eye due to her own stupidity, the lawyer [because of course, there should be a lawsuit to have somebody else pay for the stupidity] asks the eye doctor, “And did you, Mr. Eye Doctor, actually see the patient before prescribing what is a prescription and highly dangerous medical device? You did not even bother to see her?”

And the physician pays through the nose [or rather, his malpractice insurance pays or settles to make it all go away, and then raises the price of the malpractice insurance—otherwise, the patient will receive kajillions of dollars for the loss of her eye due to her inserting the prescribed contact lens into her puss-filled eye and losing it].

RE: “Please explain how this one is litigation driven.”

Once again—physicians are violating the law if they “call in” a prescription to a woman whom they have not seen for three years.  In that case, they are also violating the rules of common sense.  Why should the physician violate the law AND the rules of common sense in order to add convenience?

Finally, when I think through the thread, it also seems clear that there is a massive chasm in definitions.  Seeing one’s physician for a physical, and one’s eye doctor for an annual checkup [if one wears prescription lenses or takes ocular drugs], and one’s dentist for an annual cleaning and occasional x-rays is good maintenance.  Every three months or 3000 miles I must take my car in to get its oil changed.  Even if it “doesn’t need it.”  That’s a standard act that people who want their cars to have long lives do.

Taking the child to the doctor every time the child sniffles [around 9-10 times a year] and demanding antibiotics for something that is a cold is the “too much health care” I hear about.

Announcing that one must have a restocking of ritalin—on a Friday, right before closing—for one’s child because one is going to the beach that weekend is the “too much health care” I hear about.

Announcing that one must have a restocking of the copious amounts of pain pills one takes—on a Friday, right before closing—because one is going to the beach for a week is the “too much health care” I hear about.

Going to the emergency room for a headache—when one has no cancerous tumor in one’s head [of course, this will be determined at enormous cost by the emergency room physicians]—is the “too much health care” I hear about.

All of this, I guess, is so much pedantry anyway and perhaps not useful to discuss.  Central Planning will determine what all of us should do and not do, and will take care of all of this for us and charge whatever rate they wish, and the physicians who enjoy that kind of work will be the ones we get to use as they will be the ones who have remained in the field.  It will be just like going to the DMV or the line at the main Post Office.

Judging by the healthcare threads on T19 it’s looking like Clueless, Rob Roy, Country Doc, Capn’ Jack Sparrow and the various other physicians who comment here won’t be a part of that halcion future envisaged for us.

Good times.

September 29, 8:48 am | [comment link]
47. Clueless wrote:

“Every woman I know sees their gynecologist for their pap smear and general gynecological check up.  I have had numerous insurance companies over the years and none of them has ever suggested I do otherwise.  Even the ones that require referrals (e.g. Aetna) let every woman pick a primary care doctor AND a gynecologist and they can see the gynecologist once a year without a referral.  So apparently this is standard practice. “

Obviously you have high end insurance which is why you get away with seeing a specialist for routine care. 

This is part of the overutilization we are talking about.  It is not necessary to see a specialist for a pap smear, any more than it is necessary to see a neurologist for simple migraines occuring a few times a year.  Most family physicians can handle this, and ordinary insurance expects it.  Apparently you have gold plated insurance.  That’s nice, however the extra monies that is spent making sure that you have specialists for routine maintanence, does mean that there is that much less money in the system for folks who just want catastrophic care and can’t afford even that.

Me I have a family physician.  She does my pap, tells me it is time for my colonoscopy, sends me for a mammogram, and gives me my tetanus booster, and would give me my flu shot if I didn’t get it free at work.  She does the same for my kids.  Most people around here don’t have high end insurance.  They have ordinary insurance, medicaid and medicare, or they go uncovered and hope for the best.  I feel blessed to have ordinary insurance.  I do not suck up specialist appointments for routine pap smears (or routine anythings) and then complain that I am not seen promptly enough to suit my convenience, and that I deserve more health care, and for free, also.

September 29, 9:45 am | [comment link]
48. Clueless wrote:

Teatime said: “Steroids over the counter? Seriously? Surely you realize that chronic steroid use becomes, as my internist puts it, just like another disease to manage. Weight gain, osteoporosis, diabetes, cataracts, mood changes, and other nasty side effects ensue. “

Indeed. Yet in other countries, people study up on the side effects, speak to their doctors in order to get some guidance on how often, how much, how many times a year, and buy it over the counter.  Usually once you get a feel for it you can handle it.  It is like being an intern.  Everything is scary for the first few months, after that it starts coming into place.  If you get into trouble you see a doctor (or a nurse, or simply a smart shopkeeper/taxi driver other untrained person) who just has a lot of experience in managing insulin, steroids, whatever, until you get your medications stabilized, after which you can solo again.

It actually works pretty well if you have a smart, highly motivated person who is read and study and go get help as needed.  Obviously if you have an irresponsible idiot the results are dreadful, and many people die of fungal infections, abscesses and antibiotic resistant diseases in India because they are not able to manage their medications.  We take it for granted that people in the US should all, regardless of education or math skills, be able to fill out their income tax forms. Those who can’t are expected to find their own help.  We expect that when folks try to set up their own businesses, they will be compliant with all laws, and regulations despite the fact that these number in the thousands and change every day.  Ignorance is no excuse under the law.  Everybody setting up a coffee shop is expected to comply with the law, even if they are not lawyers.  Those who can’t do so, are expected to go find a lawyer. Science is not much harder than is the sort of mathamatical skills and legal skills that are taken for granted in this country. 

It can be done.  Very cheaply, too.  It is part of the reason health care is so much cheaper in developing countries.  But it can’t be done if shopkeepers and drug companies are going to be sued by folks too lazy to read the PDR, and too stupid to ask for help.

September 29, 10:00 am | [comment link]
49. Clueless wrote:

“It is not necessary to see a specialist for a pap smear, any more than it is necessary to see a neurologist for simple migraines occuring a few times a year.”

This overuse of health care by the worried well, who just want to feel that “by Golly I get the best; I won’t let just anybody do my pap smear”, is also part of the reason that patients with serious medial illnesses that family physicians can’t handle (vasculitis, myasthenia gravis, seizures occuring multiple times a week) are waiting 3 months to see a specialist, while the specialists are run ragged trying to fit them in, or have to see them in the ER as an emergency.

September 29, 10:05 am | [comment link]
50. Catholic Mom wrote:

Sarah,
Please note again that I didn’t say my doctor should have called in the prescription.  The point was that when I called her the day after the emergency room visit, I couldn’t schedule a visit for THREE MONTHS because notwithstanding that I had been going to her for 15 years, I hadn’t seen her for three years (because there was nothing wrong with me) so my status was re-set to “new patient” and the first new patient opening was three months into the future.

Clueless tells me I shouldn’t have expected the emergency room to give me a prescription for (one) steroid pill so that I wouldn’t have to go back to the emergency room next time I had a bad reaction to a wasp sting.  I should have seen my “primary care” doctor.  But when I tried to do this I was told that I had *underutilized* her services in the past so I would have to wait three months to see her.  Meanwhile I was actually stung again two weeks later and this when I was on Cape Cod without access to *any* of my doctors.  So the only reason I (my insurance company) didn’t end up paying hundreds of dollars again for the exact same thing is that I happened to have a friend who is a doctor who got me a pill.

Clueless—I don’t have “gold plated” insurance.  Never have.  I always have had the very cheapest policy that my employer provided or the (almost very cheapest) policy I could buy myself.  Re: what you said your primary care doctor does:  “she gives my pap, sends me for my colonoscopy and mammagram, gives me my tetanus and flu shots.”  I’m completely the same except I go to a gynecologist for an annual exam.  I don’t need my doctor to send me for my colonoscopy or mammograms (I know when those need to be done and do it myself) and she does give me a flu shot once a year.  Or rather her nurse does.  But apparently this is not enough for me not to be classified as a “new patient” presumably because she gets $17 for this and she wants me to come in for a real exam that costs a minimum of $200 and I don’t need it so I don’t do it.  Who is the one pushing “excess utilization” here??

September 29, 10:11 am | [comment link]
51. Catholic Mom wrote:

BTW, I don’t think my insurance company is paying $1 more for the pap and exam my gynecologist gives me than they would for my primary care doctor to do it.  In any event they both belong to the same “medical group” and are in the same building and use the same billing service.  I think I’m doing things exactly as they want me to except that my primary care doctor would like to see her more often which unfortunately my good health prevents.

September 29, 10:22 am | [comment link]
52. Clueless wrote:

“I don’t need my doctor to send me for my colonoscopy or mammograms (I know when those need to be done and do it myself) and she does give me a flu shot once a year”

Basically you wish the priveleges of having a relationship with a physician (to fill out your forms, and to answer your phone calls for free) while simply using the physician as an urgent care.  However the physician’s office is not run as an urgent care, which is why you have a 10 dollar copayment, not the much greater amount that an urgent care would charge. 

If you are not going to use the physician as a primary care doctor (which means the annual physical thing) then don’t expect him to act like a primary care physician 3 years, or 5 years or 10 years later, when you need stuff called in.  You want to see a gynecologist every year instead of a doc. Swell. Ask your gynecologist if she would be willing to act as a primary care doctor and call in prescription for you.  Don’t expect your internist to run your scut when you don’t even bother to check in once a year.  Otherwise you are abusing the patient doctor relationship.  Many internists I know drop patients who don’t see them in 3 years. 

Not everybody needs a primary care doc. When I was younger I didn’t bother with one.  I went to urgent cares.  If you want to have a primary care doctor then act like a primary care patient.  Not a prima donna

September 29, 10:29 am | [comment link]
53. Catholic Mom wrote:

I DIDN’T ASK ANYBODY TO “CALL IN A PRESCRIPTION FOR ME”!!!  What part of this am I not conveying??? 

I’m “abusing the doctor patient relationship” because I don’t go to my doctor when I do need her??????  Because I only try to set up an appointment when I actually need one?  I’m acting “like a prima donna” because I do exactly what I’m supposed to be doing???  Unbelievable.  And you want to know why the U.S. health care system is screwed up.  This thread makes it abundantly clear.

September 29, 10:54 am | [comment link]
54. Catholic Mom wrote:

I meant “don’t go to my doctor when I don’t need her.”

September 29, 10:55 am | [comment link]
55. Catholic Mom wrote:

OK, I couldn’t take the absurdity of this anymore.  I just called my primary care doctor and asked the nurse if she (my doctor) does pap tests.  She said no—she sends people to the gynecologist (which makes perfect sense since they are in the same practice and presumably the gynecologist doesn’t want her to take his business).  I then said “I’m told that some people go to their primary care doctors for pap tests” and the nurse said “well, some of them do it and some of them don’t.”

Yes, I am indeed an awful, selfish, gold-plated, prima donna (forgot what else) for doing exactly what I’m supposed to do.  Yes, the problem of “excess care” clearly is the fault of those awful patients.  Perhaps they could just be done away with and the doctors could just bill the insurance companies directly while cutting out the stupid middlemen.

September 29, 11:10 am | [comment link]
56. Catholic Mom wrote:

Oh yeah, I’m also a prima donna because I take excellent care of my health and stay on top of everything and know when I’m supposed to have a routine colonoscopy and mammogram and schedule those things myself instead of paying my doctor to do it.  I’m asking for my primary care doctor to “run my scut” (whatever that means) when I call to make an appointment in which she will get paid $200 to look at the report from the emergency room and write a prescription for a pill???????

Unfreakin believable.

OK.  I will be a good complacent American patient.  I will run to the doctor every time I get a cold and she can charge my insurance company $200 for it.  I will get extra unneeded duplicate physicals once a year.  I will ask my doctor to run my life for me and let me know whenever I should go for a screening exam.  All this will cost thousands of dollars and be utterly unneeded but I will then be the kind of patient Clueless wants me to be.

September 29, 11:19 am | [comment link]
57. Clueless wrote:

If you are healthy, you do not need a primary care physician.  If you don’t want to have an annual physical, don’t expect your primary care doctor to do unpaid phone calls, form fillings and maintain your medical record for free.  Just go to the urgent care. 

I am not a primary care physician.  However I respect what they do.  You clearly do not. 

As for “cutting out the middleman” it would be best if insurance were portable accross state lines. (This is illegal). Then instead of having gold plated insurance (that you clearly do not appreciate) you could pay much less, and have catastrophic care coverage only.  That would indeed cut out the middleman.  If everybody did this, we could cover the uninsured.  Unfortunately, most americans feel they deserve cheap routine maintenance (the 10 dollar copayment). This, together with end of life care, liability and regulation is the reason why costs are so high.

September 29, 11:29 am | [comment link]
58. Catholic Mom wrote:

I did not ask my primary care doctor to do an “unpaid phone call” nor did I speak to her.
I did not ask my doctor to do “form fillings” (whatever that would be).
I did not ask my doctor to “maintain my medical record for free.”
I do not have “gold plated insurance”  (that I clearly don’t appreciate???).

I have no idea who you are communicating with but it is not me.

I am very familiar, however, with the “high health care in the U.S.is the fault of the patients” arguments.  In this case you have given a beautiful reductio ad absurdum example of it.

September 29, 12:25 pm | [comment link]
59. Paula Loughlin wrote:

Bottom line, doctors are not free to practice medicine by what they and their patients believe will be the best standard for their individual care.  Catholic Mom’s doctor is not allowed to assume all is on course with CM’s health and that a simple routine follow up visit will suffice to provide CM with the required medication. 

The Doctor and his or her practice lives and dies on documentation, documentation, documentation.  A very big part of that is showing that you have the relationship of care that corresponds with the services provided.  Services such as prescriptions, testing, referrals to specialist and lab work. 

You can be very very well assured that if a doctor prescribed steroids when they have not seen a patient withing x amount of time they will (if this happens with other patients as well) be targeted as running a pill mill.  It is not just a matter of “let’s inconvenience this fine lady and frustrate her as much as possible.”  It is literally a case of “if anything ever goes wrong or if I am ever audited by the Government I better be able to show no deviation from the proscribed norms demanded by regulatory authorities.”

I see a Neurologists for my MS.  Recently I have noticed signs that he is stressed and harried.  He mentioned that the new director of his department is demanding he sees more patients.  He has to see more patients because the University cares for a lot indigent and illegal immigrant patients who must be given the same scope of care as any paying patient if the University does not want to face law suits.  Since the cost of providing care does not go away because x number of people get it for free you have to increase the volume of paying patients.  Now if the majority of those are insured patients who pay a contracted rate you have to see a lot of patients to cover the costs.  Because of this my care is compromised (not greatly) because my Neurologist can no longer spend as much time as he thinks is necessary with each patient.  He has to provide care as dictated by others.  This means more stress and some very late nights. His last set of notes for my visit were dictated at 8:32 P.M.  How can he keep going at such a pace?  He can’t and I have a feeling he is counting the days till retirement.  Which would be a shame since he is a world reknown authority on MS.  Without his expertise I would have waited a lot longer for a diagnosis. 

But the people who decide how medicine must be practiced don’t care about that.  They care about all the things Clueless has pointed out.  There is a big difference between practicing medicine and practicing government mandated care.  In the former the patient is supposed to be the primary concern.  In the latter the primary concern is political benefits.

September 29, 12:36 pm | [comment link]
60. Clueless wrote:

I did not ask my primary care doctor to do an “unpaid phone call” nor did I speak to her.  I did not ask my doctor to do “form fillings” (whatever that would be).  I did not ask my doctor to “maintain my medical record for free.”

By identifying her as your primary care physician, she is expected to do these things.  That is one of her legal responsibilities.  If you needed forms filled for the MVA, for social security for your taxes, she is expected to write them (unless they fall better into the purview of a specialist you are seeing for the problem). 

You also have responsibilities in a primary care relationship.  In addition, to taking her advice, being compliant with medications and appointments, you are expected to maintain a relationship with her (this is usually works out to seeing her every 1-2 years).  (If you don’t like her advice find somebody else. It’s a free country).

You did not fulfill your part of the primary care relationship, and you are surprised that she considers you a stranger and a “new patient” instead of somebody she has a relationship with.  The passage of time does not make a doctor patient relationship, any more than does the passage of time make any other kind of relationship.

Folks who just want their docs to treat them on the rare occasions, every few years when they have something acute wrong with them, go to the urgent care.  They don’t want a primary care doctor.  The primary care clinic is not set up to drop everything in order to provide immediate attention to folks whom they have not seen in 5 years.  It is able to fit in folks whom they know well. 

“I do not have “gold plated insurance”  (that I clearly don’t appreciate???).”

Your insurance allows you to use specialist slots for routine maintenance.  That is high end, even if you don’t realize it.  It is also a waste of several years of specialty training at a time that folks who have ovarian tumors are waiting long periods to get into a specialist.  Of course it may well be that your state does not allow any insurance other than high end.  Obamacare also insisted that all insurance be, in effect, high end.  However the solution would be to permit you to buy insurance accross state lines that does not involve going through a primary care physician. That would be cheaper for you, and more in keeping with your philosophy of health care which is “I don’t want no stinking relationship, just give me my shot and give me antibiotics when I say so”.

Not everybody needs or should have a primary care doctor.  It is fine to go to urgent care clinics. It is not fine to treat your internist like he is running an urgent care clinic.  He is not.  There is a difference between the primary care philosophy and the urgent care philosophy. If you dont like it, don’t use it.  Use the urgent care. That is what it is there for.

September 29, 12:41 pm | [comment link]
61. Sarah wrote:

RE: “And you want to know why the U.S. health care system is screwed up.  This thread makes it abundantly clear.”

Yes. 

It certainly does.

RE: “Of course it may well be that your state does not allow any insurance other than high end.”

Clueless puts a finger on another big driver of costs.  We have health insurance plans that are LEGALLY forced to have benefits larded onto it that most of the people don’t want or need.

We need to be able to purchase insurance across state lines.  And insurance companies need to be allowed to *customize* insurance policies for lots of different needs and wants and groups rather than the legally mandated extras that add huge costs to our insurance costs.

That, plus tort reform, plus easing of the regulations on HSAs, plus eliminating the whole certificate of need scam would go a long way towards lessening costs for those who are interested in paying for their healthcare.

Of course, we are going in the opposite direction, plus having to pick up all the folks who are not interested in paying for their healthcare.

It’s going to be a long long decade.

September 29, 2:02 pm | [comment link]
62. Bookworm(God keep Snarkster) wrote:

“There is a big difference between practicing medicine and practicing government mandated care.  In the former the patient is supposed to be the primary concern.  In the latter the primary concern is political benefits”.

Or, in the latter, it’s money, money, money. 

I realize that sometimes that’s necessary to keep certain health care facilities open and afloat.  But, when this country decided it was ok to take on a boatload(at least, no pun intended) of uninsured illegals, it set itself up for a world of trouble, as Paula outlines in 59. 

I’ve had my own experiences, too, as a health care provider; once in one of the largest, best, Level I trauma/heart/tertiary care centers in the country.  I saw the “correct” number of patients and provided quality care.  And still the bean counters were on our cases(me and the other two women that provided care in our department).  I told the supervisor, “Add on any more appointments and you will possibly detract from the quality of care”.  And she said, “Your job is not to ‘provide quality care’, it’s to increase business”.  I guess at this 4-star facility they ultimately wanted patients dead on operating tables, if my pre-op assessments were shoddy or wrong.  This is not very Christian, but it was all I could do not to smack that pompous, rat-faced woman, with whom I had wrangled once before over a very important issue(she probably didn’t like the fact that I was right about that one, too).  But, I did get nose-to-nose with her and say, “Well, if you truly know what you’re doing, you can do both; but, in any system there is always a such thing as “overload”.  By choice I did not work there very much longer, as that department’s priorities were nowhere near mine. 

Complicated issues, all around… hmmm

September 29, 2:55 pm | [comment link]
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