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The Cost of a Doctor Visit – Where is the Value?

Man Holding Money in Doctor Outfit with Smirk ExpressionThis post at Kevin MD made the rounds again last week. Written by Mary Pat Whaley, and entitled , “Your 10 minute office visit needs 8 people and 45 minutes of work” it describes all the background work that takes place before, during and after a doctor visit so that patients won’t be so surprised that their visit costs so much money.

It’s an important perspective for patients to understand, certainly.  While most of us realize that there is much more that takes place behind the scenes than we are aware of, we really have no idea what it takes to support just one 10 or 15 minute appointment. This is a good overview, even if three years after it was first published, most of us experience it differently due to the shift to electronic records.

That said…  to Mary Pat and others who want to defend that $100 charge – we patients still don’t get it, no matter what explanation has been provided.

We’ll ask you instead to look at it from our perspectives:  We have just spent an hour in your office waiting for our drive-by visit with the only person we really came to see. Then you tell us it cost $100 for that 10-15 minutes, which we translate to $400 an hour for his or her time. Further, from our perspectives, all he did was ask a few questions, embarrass those of us with modesty issues, and then leave. We rarely feel any smarter.  Some of us feel belittled and unworthy.  And then we are expected to pay for the insult.

Suppose you were treated the same way by any other service you needed yourselves…  What if your car mechanic treated you like that? Or your hairdresser? Or your accountant or lawyer?  You know you would walk away, no matter how they justified those charges to you.

So – let’s look at this another way:

Continue reading ‘The Cost of a Doctor Visit – Where is the Value?’

Sometimes It’s Better to Just Say No

Story One: When I was a child (and we’re talking a lo-o-o-ng time ago – when doctors made house calls)… if I got an earache, I would suffer.  REALLY suffer. Mom would drip some warm oil into my ear, and then stuff some cotton in behind it. She’d give me an orange flavored baby aspirin or two.  And I would just lie in bed, or on the couch, miserable.  MISERABLE.  Seems like I would sleep a lot. Two days later, my earache would be gone, and because I was a kid, and resilient, I would be back on my feet.

Story Two: When I was a kid, I fell off my bike as I flew around a corner near my house.  My bike flew off in one direction and I flew in the other, and landed smack on my elbow.  OH THE PAIN!  I pulled the cinders out of my arm, and cried all the way home as I dragged my bike with me.  That evening my dad walked me across the street to see a doctor who lived in our neighborhood.  He felt along my arm, moved it around a little, declared that I had sprained it, then put my arm in a sling where I was expected to keep it for the next few weeks.

Perhaps it’s miraculous that I survived childhood!  But I don’t think so.  I think any of us over a “certain age” had very similar experiences as a child.  We all had sore throats and earaches, we all sprained and broke bones – and we didn’t have the miracles of modern medical care to help.

Fast forward to today.  Today when we go to the doctor, no matter what the complaint, we are met with a barrage of tests, procedures and treatments.  If I had a sore throat and an earache in 2012, I would likely be given a strep test (chi-ching!) and prescribed an antibiotic (chi-ching!)  If I fell off my bike in 2012, I would be given at least an X-ray (chi-ching!), but more likely a CT scan.  I’d be prescribed an antibiotic (chi-ching!) and maybe even a pain killer (chi-ching!)  I’d need follow up testing to see how well everything was healing (chi-ching!)…

Bottom line – healthcare is so much more expensive today because we do things that we don’t necessarily need to do.  We are herded into services that we don’t necessarily need.  And (shame on us) we ASK for things we don’t necessarily need and probably shouldn’t get.

Don’t need?  Shouldn’t get?

Antibiotics, the miracle drug of the 80s and 90s, were so overprescribed that today the bugs they were intended to kill have evolved into superbugs. People die from acquiring infections that didn’t become problematic until the overuse of antibiotics.  Yet – mom takes her child to the doctor with an earache and insists an antibiotic be prescribed for her child.  Two days later, the child is no longer in pain.  (But is that any improvement over the two days it took me to get past my earache 50+ years ago?)

The existence of CT scanners, MRI scanners and PET scanners, and the need to pay for them, compel doctors to order those tests, even in cases when they may not be necessary.  Of course there are times when they are very necessary – but not always, and not as often as they are used now.  When it comes to so much extra scanning, it can create big problems for our health (too much radiation exposure from x-rays or CTs) AND our wallets – imaging is expensive, even when we have insurance.

So how can we know the difference?  How can we be a bit more savvy when it comes to test and treatments, whether or not they are suggested by our doctors?

Last month, a consortium of nine different medical specialties – the very doctors who make money when we have tests and treatments – came out with their lists of tests, treatments and procedures we patients don’t need.  They listed them all on a website, called Choosing Wisely.

If these doctors don’t think we should take these tests, then why would we have them?

What we know is that this elite group has made these recommendations.  What we don’t know is that those recommendations will filter down to the doctors who order these tests, treatments and procedures – because that’s how they make their money, and (they think) that’s how they can defend against lawsuits.  (We can only imagine how unhappy that orthopedist who makes his living running CT scans is with his own peers that tell patients not to get so many CT scans.)

So, knowing that our doctors may not be aware of the lists, or may have chosen to ignore the lists, it’s up to us patients to ask questions.  “Doctor, If I take this antibiotic, how soon will I feel better?  How soon will I feel better if I don’t take it?”  — or — “Doctor, I know an X-ray is much less expensive than a CT scan.  What will a CT scan tell you that an x-ray won’t?  Can I have just the x-ray?”

So yes, fellow empowered patients, it’s time for us to begin making smarter choices, both for our wallets and for our health.  Make yourself generally aware of the new recommendations of tests, procedures and treatments you just don’t need.  Understand that leaders in healthcare who understand about reining in costs, even if they are the ones who lose income, are calling out to their peers to make changes in their recommendations….

Unfortunately, anything in medical care takes a LOT time to implement.  But this is something we patients can do – and do with no detriment to our health OR our wallets.
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Time to Put a Stop to Drive-by-Doctoring

As many of my readers know, I speak at meetings and conferences fairly frequently, and most often to groups of patients and caregivers. The focus of the talks I give is usually on a patient empowerment topic – ranging from how to communicate with your doctor, to how to stay safe in the hospital, to a dozen other topics….

Every time I speak to groups of patients, I ask the question, “Have any of you ever felt rushed during a doctor appointment?”

The overwhelming majority raise their hands, and nod, and often turn to the person sitting next to them, poised to share their latest horror story about being rushed, which is often the case after they’ve waited in the waiting room for way too long.  A double whammy.

Frustrating. Maddening. Unfair.  And now, statistically accurate, including its negative effect on both our health and our wallets.

Newsweek Magazine published an article this week called The Doctor Will See You – If You’re Quick.  Written by Shannon Brownlee (author of Overtreated), it quantifies the problem of, what I call, “drive by doctoring” – the concept that we barely see the doctor walk IN the exam room door, before the doctor has retreated back out that door, asking the empty hallway (because he’s no longer engaged with the patient at all), “Do you have any more questions?”

The point to the article (which is excellent – you really should take the time to read it in its entirety), is that over the past few decades, the trusting relationship that used to exist between patients and their doctors has eroded to almost non-existent, and has resulted in bigger problems for both parties.  And both parties are suffering.  Patients don’t like it, and their doctors don’t like it either.

Or (another one of my sayings) – American healthcare is not about health or care. It’s about sickness and money – using sickness to make money.

Here are some of the points that support that:

  • The ideal patient panel (number of patients) for primary care doctors should be fewer than 1,800 patients in order to provide the kind of care patients need.  Today, the average number of patients per PCP is 2,300. And for “Medicaid Mills”, the panel is more like 3,000.
  • To speed things along, doctors interrupt their patients an average of 23 seconds into the answer to the question, “Why are you here today?”
  • One study showed that the average amount of time spent providing “critical information” to patients is 1.3 minutes (yes – that’s MINUTES.)  Your quality or quantity of life only deserves 1.3 minutes?

To those of us who understand this madness, and attempt to be smart patients, there is nothing new here. But the information is beneficial to us for a few reasons:

First – because our world is being driven more and more by data, and not simply our observations and stories. With the quantification of these kinds of problems, the powers-that-be will have to look at solutions, because no nation can afford sicker and poorer people.

Second – because this kind of information is a good reminder to us all that it’s us SMART, EMPOWERED PATIENTS who will manage to get the best of a system that has the capability to be great, but is growing worse every day.

We can’t help those who won’t help themselves… but we can be the ones who will STOP this erosion, and help ourselves.

•  Helping ourselves will mean we find the right doctors - the ones who WILL communicate with us. (A reminder that no doctor is average – they are either better than, or worse than, whatever average is. As empowered patients, we search out the “better than”.)

•  Helping ourselves means we place ourselves squarely in the middle of our own medical decision-making - we don’t default to letting someone else make them for us.

•  Helping ourselves means we find information to support our decisions, making sure it’s credible and reliable.

•  Helping ourselves may mean that we try to manage our relationships with our doctors on our own, or it may mean we ask someone else to help us.

•  Helping ourselves will mean understanding the roll the pursuit of profit takes on our health – we will understand the concept of Follow the Money and why that makes us poorer and sicker.

It took decades for the healthcare system to devolve to what it is today (just in time for us baby boomers to utilize it in huge numbers with, in too many cases, horrible outcomes.) It will take decades more to fix it.

Most of us don’t have decades to wait – and for that reason alone, we must engage in our own care.  We can’t afford, for our health OR our wallets, to let drive-by-doctoring take its toll on us or our loved ones.

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Who’s Really a Patient? Skewed Opinions Result from Inside Information

That seems like a fairly simple question, don’t you think?  Who really is a patient? But the answer is actually more complex than you might realize.

Among the possibilities:

1.  anyone who has ever accessed medical care is a patient – which includes everyone, no matter what their relationship is to the healthcare system (so, for example, doctors would also be considered patients, as would any other provider, or even payers like insurance company employees, or pharma employees, etc.)

2.  anyone who has accessed medical care, but doesn’t have inside knowledge of the healthcare system, is a patient

By dictionary definition, the answer is #1: that anyone who ever accesses medical care is a patient.

But when it comes to defining a patient’s perspective, his or her point of view, then the answer is not so cut and dried.  In my (not so) humble opinion, a medical insider cannot possibly truly understand a non-insider patient’s point of view about their healthcare experience.

Here are some examples:

  • When a doctor, nurse or other provider finds troubling symptoms,  s/he doesn’t just make an appointment, then wait for days or weeks like the rest of us do before we see a doctor.  S/he calls a friend and gets in to see him or her right away.  So – what is that patient’s perspective?  Is the point of view going to be the same? No.
  • When an insurance company employee needs a medical test or payment for a claim, s/he knows from the inside how to get it taken care of.  Is that the same perspective as someone who struggles to get those services?  Is the point of view the same? No.
  • When an insider, who is getting paid under the table for prescribing certain medications or is rewarded by a medical device manufacturer for using that company’s devices (think artificial hips and knees, or spinal fusion material, etc), is asked about the cost of care, they can’t see it the same way as the patient who needs that new hip and doesn’t have insurance.  Do they have the same point of view about their needs?  No.
  • When a popular doctor has surgery in his own hospital, in a private room, where the nurses respond quickly to the call button (because he IS one of their favorite doctors!), and is then discharged with no infection, do you think his perspective can be nearly the same as a Medicaid patient treated in that same hospital?  Yet – they are both patients in that hospital.
  • When the director of the “National Cancer Awareness and Prevention” charitable organization, the majority of whose budget is underwritten by a handful of pharmaceutical companies, is asked to represent patients on a conference panel to discuss the development and cost of cancer drugs, how objective can her opinions be?  Does she dare step on those pharma company toes by saying what a ‘real’ patient might say?

The subject came up most recently when yet another large, influential healthcare organization decided to hold a “patient and caregiver” forum to discuss “patient-centeredness” – and yet, once again, there were no non-medical-care-industry patients included as expert speakers.  Seriously.

It also reminds me of the many times I have approached healthcare conference planners, offering my speaking abilities, representative of that important patient point of view… and they were not interested.

Their response?  “We are all patients.”  (See #1 above.)  But if what they are trying to do is help patients – well – wouldn’t it be a good idea to ask a patient who isn’t an insider to chime in? Evidently not. They only wanted speakers who were from their industries.

Put another way:  it would be like GM or Honda designing cars without ever asking the opinions of car buyers, or JCPenney only selling size 4 dresses because they never assessed gender or the sizes of their shoppers.  They would swiftly go out of business….  which, of course, doesn’t happen in healthcare because we “consumers” (I hate that word in healthcare) don’t vote with our feet.

I think we need a way to make the distinction. If we are all patients – then what can we do to distinguish between those who do, or don’t, have a “real” patient’s point of view?  Are we, as non-insiders, “pure” patients?  Or are we “unencumbered patients?”

Or, maybe we do the opposite, and use a term to describe those patients who are insiders.  Maybe we call them “industry patients” or “insider patients.”

Or – maybe I’m missing the boat entirely….

This matters. It matters because when non-industry-insider patients are expected to be the representatives of a non-medical-industry-insider’s point of view, that point of view, and the results, get skewed.

And for us patients who don’t live inside the medical industry:
Skewed = Screwed …  In more ways than we can count.

What do you think?  Do you see the distinction?  While we may all access medical care, do you agree that our points of view are different?  What do you suggest we do to help the medical care industry understand and embrace the difference?

Please provide your 2 cents below.

…MORE…

Patients – The Invisible Stakeholders

The Myth of “Doctors Are Patients, Too”

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A Dose of Reality – Today’s Doctor Appointment

Please note that this column first appeared in the Syracuse Post Standard
October 11, 2011

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In the “old” days, we could phone for a primary care doctor’s appointment in the morning, be seen right away, spend enough time with the doctor, leave with a treatment plan, and usually feel better within a day or two.

But no longer! Today it’s difficult to get an appointment, even within a few days. We sit in waiting rooms far longer than we expect. Then when we finally see the doctor, we often feel like we’re being rushed out the door.

We patients tend to blame our doctors and the way they run their practices. Why should we have to wait so long? Why won’t they spend more time with us?  What’s the big hurry?

The truth is, your doctor doesn’t like today’s limited time system either.  He would love nothing more than to be able to make immediate appointments, see you the moment you arrive in his office, and spend plenty of time with you, too.  But the insurance reimbursement system doesn’t make that possible.

Last week I had the opportunity to work with personnel at North and Northeast Medical Centers.  I was asked to help them help us patients manage this time-constrained reality we are all stuck with to improve patient satisfaction. I suggested some steps they can take to help their patients get the most from their appointments.

But the patient-provider relationship is two sided. We patients need to take our responsibilities in that relationship more seriously, too.

We can do so by preparing ahead of our appointments:

First – Write down anything that is new since your last appointment. New symptoms, new aches or pains, new supplements you’re talking, drugs another doctor has prescribed, or new triggers you’ve discovered that create problems for you. Record them along with the dates they started.

Second – Take a list of every drug and supplement you take, including brand names and dosages.  Note any that will need renewal within the next 90 days.  Or, instead of listing them, throw the containers into a bag and take them with you.

Third – Write down your questions. Prioritize them since you’ll only have time to ask two or three.  If you have more than one medical problem, and therefore extra questions, then make an additional appointment.

Being a prepared patient will make every interface with your doctor more effective and efficient. You’ll be more likely to get what you need – a collaboration that’s beneficial to you and your doctor.

……………… ADDITIONAL RESOURCES ON THIS TOPIC ………………

 Effective Patient-Doctor Communications

Why Do I Wait So Long for my Doctor Appointment?

Are You Prepared for Your Doctor Appointment?

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Want More Patient Empowerment?
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Every Patient’s Advocate

About.com Patient Empowerment

…and…
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