doctors and groceries and rules

When I see my doctor for a routine check-up, he wants an updated history.  The paperwork he gives to patients for writing that history includes the question, “What concerns would you most like to have addressed today?” and allows space for three short answers.

Sometimes, based on my answers to this question, he has billed for both a physical plus a mid-level appointment.  I’d had no idea that writing something on those little lines turned the appointment into a routine physical plus an extra appointment.  I’m not complaining; my doctor listens to me and always addresses my concerns, so I’m happy to pay whatever is owed.

It was with a bit of surprise, then, that I discovered that this might be a problem.  It doesn’t take much time in the blogosphere to discover that there are doctors who want to limit the number of issues they’ll deal with at one time.  Some doctors say one complaint per visit.  Some say keep it to two or three.

That seems crazy.  When I buy groceries, I go to the store and purchase everything that I need.  I don’t go today for bananas, then tomorrow for tomatoes, and the next day for olives.  I make a list of everything I need, then go to the store one time.  Only when the cupboards are looking bare do I scrape together enough energy to go to the store again.

Like going to the store, I thought it was reasonable to go to the doctor as seldom as possible.  Once it couldn’t be put off any longer, I’d make a list for the doctor and assume that he’d bill based on the complexity of the appointment.

My doctor never indicated frustration with my approach.  Had I known, I could have found a way to make separate appointments for separate issues.  Or at least requested two time-slots when I phoned to schedule an appointment.

The last time I was in my doctor’s office, however, I noticed a new sign on the wall:  Important Information Concerning Multiple Problem Exams.  All concerns will be addressed, however insurance might determine that a second copayment is due based on the complexity of some issues.

It turns out that there are rules to seeking medical care, but patients aren’t allowed to see the rule book.  Everything we know about doctor/patient interactions was picked up from parents and friends, and those people might have been (probably were) wrong.  It’s a case of the blind leading the blind.

Those who know the rules – the doctors themselves – are in the perfect position to teach patients what the rules really are.  That’s one reason I like reading medblogs – and have changed my approach to my doctors based on the things I’ve learned.

Dr. Synonymous  has an interesting post pondering how doctors and patients can protect their relationship.  None of that Patient Centered Medical Home nonsense, where a zillion people come between the doctor and the patient.  I really like DrS’s concept of the Human Centered Health Home, with patients and doctors respecting one another’s time.

I want a rule book!

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19 thoughts on “doctors and groceries and rules

  1. I know exactly what you mean. Usually it’s not a problem for me as many times as I HAVE to see my doctors for follow up anyway. But while recovering from rotator cuff surgery on my right shoulder, I also wanted to talk to my doctor about range of motion on the left shoulder replacement. The right shoulder was still covered under “free” post-surgical visits while the left shoulder was “out of warranty” (so to speak). I wound up making a separate appointment specifically for the left shoulder.
    Not everyone has the frequent access to doctors that I do, Socks and it’s good that you brought this up.
    I think doctors should print rule books.

    • Good example. I saw something similar just last week. I was at my doctor’s office and a lady was blocking the check-in counter. She was “just getting her bandage changed” so there wasn’t supposed to be a copay. Except that she also needed her prescriptions renewed, and that did require a copay. She was extremely upset. “It’s just the same pills I always take! There shouldn’t be a copay. I should have just called and had them renewed over the phone!” Everyone in the waiting room was rolling their eyes. When that person finally went left, someone said, “I don’t work for free, and don’t expect my doctor to, either. That’s why you owe a copay.”

      It would be so nice if we could book back-to-back appointments so that the doctor could get paid appropriately AND we only had to make one trip. I hope your shoulders (both) get to working perfectly for you!

  2. Terrific topic. However, you didn’t mention (and may not have known) that it is against some insurance policy (possible contract)for doctors to tell patients what the rules are. One of my doctors told me this in confidence. The fact that the insurance “rule book” is off limits to patients seems highly suspicious to me and reinforces my belief that medical care has become more about profit than patient service.

    I am fortunate that I have found a wonderful integrative internist who does not accept any insurance. He has a six months waiting list for new patients. His cash fees are much lower than the cash fees mainstream doctors in this area charge because he doesn’t have to pay his staff to deal with insurance approvals and paperwork. His first patient visit is an hour and a half and follow up visits are 45 minutes. That gives the patient and doctor enough time to review all of a patients’ issues in one visit.

    • From reading some of the comments, it sounds like not only are doctors sometimes prevented from explaining the rules, they don’t even know what the rules are! I’m glad to hear that you’ve found a doctor who’s working for your situation :)

      I’d never really thought about the fact that doctors who don’t accept insurance would be able to charge less.

  3. Great topic. The rule book is a great idea. It can be generated via the patient blogosphere and the Medical Industrial Complex will have to respond. Think about that. I believe it’s true.

    A lot of this subject also relates to business models. What model or models are used by the patient, the doctor, the patient’s employer (or the government) and the third party payers. What contracts bind each party to what kind of behavior? It gets complex quickly.

    Our Human Centered Health Home is a model that may help to refocus the work of the two humans in the engagement who become patient and physician in other aspects of the relationship.

  4. WarmSocks, your question/plea for the rule book is the key question in all of health care (two words= about health, healthcare one word= about money). You are “spot on”. No one really has the rule book. NO ONE! That is THE PROBLEM!

    • Thank you for your comments. Maybe through the blogosphere can generate a rule book. I’ll throw in my $.02, but it seems like all the different perspectives are needed for a rule book to really be helpful.

      I’ve worked in employee benefits on the employer’s side, I’ve purchased private insurance, obviously I’ve been a patient, I even have friends who work in insurance, but I don’t know how it works from the physician’s side of the equation.

      I’ll think more about this.

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  6. Another frustrating thing for doctors (I am a family physician) is that we have no part in writing these rules, often do not know the rules ourselves, and the insurance companies will not tell us the rules until we have inadvertently broken them somehow. And yet when they deny payment for something, the insurance company is quick to tell the patient that “Had your doctor coded the visit differently, we would have paid for it.”

    • The more I hear about how insurers treat doctors, I’m amazed that anyone is still accepting insurance.

      If patients knew what their insurance was supposed to cover, and knew how to communicate that to doctors, would that make things any better?

  7. An excellent topic . . . trouble is, hardly anybody knows the rules, and as a family doctor I wish I did (then I would know how to inform my patients, and I could probably save them money and make more money myself at the same time. Every insurance plan has its own rules, and they are usually impenetrable and complicated (assuming anyone, including the doctor, is allowed to see it!) . . . I once asked the CEO of my state’s Blue Cross Blue Shield if we have have some details of the rules, and his reply was that they have 450 plans in my state alone, and they are all different . . . in short, no! I agree completely that it makes sense to deal with everything at once, and not to keep coming back for separate visits . . . the snags are
    (1) the doctor doesn’t know if you are coming in for a sore throat or for a sore throat plus your regular diabetes, high blood pressure, high cholesterol visit, or all of the above plus new chest pain, ominous sounding symptoms that could be cancer, impending divorce, suspicion of ADHD . . . you get the picture . . . so we don’t know if this is 10-minute visit or a 45-minute visit, and we hate to keep people waiting almost as much as we hate to rush through potentially serious problems
    (2) the doctor will not get paid a cent more for sore throat + diabetes + high blood pressure + diabetes than he would for dealing with ALL the above problems
    (3) there are insurances that will pay for an annual physical (ie. “well care”) and some that will not, and your doctor doens’t know which are which, there are insurances that will pay for certain lab tests every calendar year but others that will not pay if it has been only 364 days since the last time the test was done

    Bottom line – it is a crazy dysfunctional nonsystem. I never tell patients they are allowed only so many problems per visit, but sometimes I do end up running late, I probably seem to be in a hurry, and I am stressed and risking burnout. Mahatma Gandhi was asked what he thought of western civilisation, and he said “I think it would be a good idea” – that’s my answer when I am asked what I think of the US health care system!

    • There should be some overarching rules that always apply, regardless of the details of specific plans.

      I think it is wrong that doctors aren’t paid more for higher complexity visits. Insurers take nearly $1000 per month from families, and don’t pay out anywhere near that amount of money; they could easily adjust the payment scale so that things are simultaneously easier on patients and fairer for doctors.

      Ghandi’s I think it would be a good idea! :D

  8. I agree! I want to be a good patient, but sometimes I am just not sure how to be. Often when I feel like I don’t know what is the right thing to do, I just do nothing and ignore whatever I wanted to deal with. A rule book would be great! I guess blogs are second best if getting a rule book isn’t possible.

  9. Using the commercial analogy, my mechanic will often limit me to what I scheduled an appointment for. If I scheduled a brake job and then state that I also want a “tune up” and oil change, he may ask me to schedule another appointment. All depends on how busy he is. I suspect it may be the same with docs. If the schedule is light, address a few more problems. If the schedule is booked, you can’t inconviencve other patients who are waiting.

    When shopping, you use your time; you only use the “doc’s” time when you check out; and we all know how those folks make us feel when they are checking out and then run back into the store to get one or more items! :-)

    • Good point. And sometimes when I take my car in, I say, “It’s making a funny noise and isn’t working right. Can you figure out what’s wrong and fix it?”

      Sometimes the doctor has to do a little more detective work to figure out what’s wrong. It’ll take extra time.

  10. I wish people in this thread sat in my waiting room! Our patients do not seem to have the same understanding of the time issues, and I’m not sure would really want to see a rule book. Everyone is busy, and it takes time away from other tasks to go in to see the doctor; patients often feel their time is not “respected” by the physician, because physicians typically are not able to stay on schedule. My patients do not want to make several appointments for several issues – they want them all handled during their 15 minute time slot – though do not think it is appropriate to be delayed because every other patient feels the same way.
    Patients are consumers of healthcare, and understandably want to get the most for their money. I am not a mechanic, and may think the tune-up is more important that the brake job, and would really appreciate the opportunity and understanding from not only the patients, but more importantly, those insurance companies with their rules books!

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