Those who feel entitled to our time and attention (article)

notshanarishona

Tue, Feb 24 2015, 11:17 pm

southernbubby wrote:

Where do we draw the line, however, on compliance? My doctor just prescribed Prolia for osteoporosis. The possible side effects could be incapacitating and many have spent months in bed due to a bad reaction to Prolia. I don't want to take it. Am I non-compliant? Does the insurance have to cover me for osteoporosis related problems if I don't take it?

Most insurers jack up the price for smokers and for the obese.

I would make some type of rule lets say that each patient is entitled to a 2nd and 3rd opinion. If 3 different dr.'s all say a person has to do something for their health (as opposed to a recommendation) then the insurance should not have to cover care for that.

For example, I think gastric by pass should be covered (once). The people who go through it 5 times because they can't control themselves and keep eating I don't think that should be on the public dollar.

Fox

Wed, Feb 25 2015, 11:56 am

southernbubby wrote:

There is more to it than that. When someone has no insurance and no way to pay and goes to the ER for anything, the costs are passed on to everyone else. They go to the ER because the ER has to take them, even though it is usually not a real emergency.

But again, is that exclusively the fault of irresponsible patients or also related to a broken medical system? I've frequently seen or experienced the following scenario:

A child is sick with symptoms that, rightly or wrongly, seem alarming to the parent. The insured parent calls the pediatrician's office and talks to a receptionist with no medical training who serves as the gatekeeper. She tells the parent to administer fluids and acetominephen, and offers an appointment in 2 weeks.

The child isn't better by the next day, so the parent calls back. The receptionist grudgingly turns the call over to a nurse, who repeats the same advice. The parent attempts to explain that this advice has already been tried, but the nurse is harried and cuts the parent off. "We don't have any available appointments today. If you feel it's really serious, I recommend going to the emergency room."

Eventually, the parent becomes frightened enough to take the child to the emergency room, where they sit with at least a dozen other families in the same boat. Meanwhile, the full technological resources of a trauma center are being utilized to treat what is probably the flu -- but every single test must be run to eliminate more serious possiblities.

It's not just the emergency rooms have become the treatment option for people who can't pay; they have become the first line of treatment for everyone whose established health care providers don't have time to treat them.

Every family physician should have walk-in hours, and hospitals should have urgent care clinics attached to their emergency rooms so that we don't bring the full force of trauma center technology to every ingrown toenail. That would save enough money that the issue of moochers and takers would be minor.

notshanarishona wrote:

For example, I think gastric by pass should be covered (once). The people who go through it 5 times because they can't control themselves and keep eating I don't think that should be on the public dollar.

This would be great if we understood what causes obesity and if that cause was something that could easily be controlled. But that's not the case. It's more complex than that, as are addictions to nicotine and other drugs. I think most of us are uncomfortable penalizing people for the medical knowledge we *don't* yet have.

Fox

Wed, Feb 25 2015, 1:15 pm

sheep wrote:

Fox - where I live there are urgent care clinics. I love them - they've saved us many an emergency room visit. I honestly don't understand why every hospital doesn't have them.

I do actually notice some improvement: hospitals around me aren't necessarily introducing urgent care clinics, but they are introducing a service that allows you to call or go online to "schedule" an emergency room visit. A nurse then calls you back and discusses your symptoms and makes a recommendation. Even if he/she agrees that your problem is emergency room-appropriate, they can schedule people with non-life threatening problems and manage staff and wait times better.

Also, I notice that urgent care clinics in drug stores and discount stores now accept insurance (at least in Illinois), which is another way to lower medical costs for everyone.

I just read this article from the Huffington Post, which describes how New Mexico saved $68 million simply by establishing a 24/7 hotline where people can talk to an RN.

(Sorry -- I can't post a link): http://www.huffingtonpost.com/......html

That savings comes *despite* the nurses claiming they are "conservative" when it comes to sending people to the ER -- meaning they send patients to the ER if there's any question that it's prudent.

If Dr. Pottash was intending to convey the frustration of trying to help people who can't or won't be helped, I completely understand -- but many of us have jobs in which we see resources wasted horrifically because people won't listen to or implement good advice.

I work with non-profit organizations and their data management, and I could write dozens of essays like Dr. Pottash's about how tzeddekah money in the Jewish community is wasted by hubris, arrogance, and an insistence of doing the same things over and over again -- even when they don't work. Yes, it's frustrating and demoralizing -- especially when you see those same organizations pleading for more money. But that's my job.

However, if he's attempting to make a statement about distributing medical resources, he's clearly barking up the wrong tree. Of course, there will always be people like his patient, who cannot seem to function in society or conduct their own lives with the slightest responsibility.
They're an easy target, but they're not the real problem.

ora_43

Wed, Feb 25 2015, 4:25 pm

I do think the system is the main issue.

In Israel, it's cheaper to go to a doctor's office than an emergency room, except it's an actual emergency or you have a referral. So that keeps emergency room visits down somewhat. AFAIK in the states it's the other way around for a lot of people, or at least, was until recently.

I (briefly) knew someone in the states who was diabetic and couldn't care for herself for various reasons. Going to the emergency room every few days was pretty much the only way she got medical attention. (She died, because unsurprisingly that's not an effective way to manage diabetes. No blame to her, mind, from what I could tell she wasn't even clear on what the medicine was. It was a sad situation.)

This was ages ago, and from what I hear there has been improvement in the system in the states since. I'm just using it as an example to support what Fox is saying.

But - emergency room visits and emergency room overcrowding aren't entirely the same issue. Overcrowding usually means that someone somewhere decided not to allocate the resources for enough rooms and staff to treat everyone.

In other words, it's not like if chronically ill patients all took superb care of themselves, there wouldn't be a long wait in the emergency room. If there were fewer patients in the emergency room, someone in management would have said "excellent, we can cut staff in the emergency room" and the wait would be the same.

Fox

Wed, Feb 25 2015, 4:41 pm

Mama Bear wrote:

fox, is that a normal scenario where you live? Here in Brooklyn, every pediatrician has multiple available appointments that day. If you call to say your baby's sick, your pushed in. I dont get what pediatricians do if not sick visits. How many well visits do they even have a day? There's no need to wait 2 weeks for an appt... Even well vists need just a day or so to schedule. that's how it works here in brooklyn.

It depends on the size of the medical practice, but it's definitely not uncommon. Obviously, I'm a tad out of touch now that my kids are older, and I do know of at least one pediatric practice that has two walk-in hours every morning. Maybe things have gotten better since my kids were small, but I think the problem still exists to some degree.

OOTforlife wrote:

I've never heard of a receptionist giving medical advice. At our peds office a question about symptoms goes to medical personnel.

All too common in my experience. Admittedly some of these staff members have *some* medical training (e.g., the equivalent of a CNA) but many learn on the job. You can usually tell because they are utterly mystified when you use any medical terminology.

questioner

Wed, Feb 25 2015, 4:45 pm

Mama Bear wrote:

Same here for sick visits by my pediatrician. I always get an appointment within a couple of hours and took that for granted. The flip side is that wait times can be terrible if they squeezed in too many children that day.

Ora, I also pay a lot more to go to an emergency room than a drs office, and after 3 emergency room visits, the (formidable) price doubles. I would never just go to an emergency room because I couldn't get an appointment.

Barbara

Wed, Feb 25 2015, 4:50 pm

Fox wrote:

In a lot of ways, I think these are artificial dilemmas created by a broken medical care system.

Linking health insurance directly to employment is one problem. The undermining of the free market system by Medicare is another. The effect of the tort system on caregivers is also at play.

The reason that health care is so expensive and resources often so scarce is *not* primarily because of a small minority of significantly non-compliant patients. The problem is much, much bigger:

* Linking health insurance to employment is a historical development and has become ineffective as rates have risen. While I'm not a particular fan of our President, there has to be *some* mechanism for allowing people to purchase insurance not linked to their employers at affordable rates.

* With most goods and services, the value of an item is based on the cost of manufacture, transportation, and a reasonable profit to all those involved. If a pair of scissors, for example, costs $2 to manufacture, $.50 to ship, and all parties involve take a profit of $2, the retail cost will reflect $4.50 plus any taxes.

The unexpected consequence of Medicare (and to a lesser extent, Medicaid) is that a bureaucrat decides what the reimbursement rate will be, and this sets the value. If Medicare decides that a pair of bandage scissors will be reimbursed at a rate of $7, then that becomes the price for everyone. It leads to a surreal environment in which there is little relationship between production costs and price.

* Why do ER visits involve such long waits? Not because of non-compliant patients. Rather, because physicians order all kinds of tests and treatments that are medically questionnable but can be used in a lawsuit defense. This happens not just in ERs, but in virtually any medical environment. Reforming malpractice claims would save enough money to adequately care for the most irresponsible bums -- but personal injury lawyers lobby hard against it.

Arguing over who should get priority in treatment is simply rearranging the deck chairs on the Titanic. It keeps us sniping away at one another while the real underlying problems fester and undo any progress we make.

Piggybacking ...

We allow the medical profession to decide how many doctors there will be, through medical school accreditation, rather than leaving it to market forces. Also, government loans are not tied to servicing under-served communities. We have plenty of doctors in New York City. Parts of Alabama, Arizona, Idaho, Illinois, Louisiana, Mississippi, Missouri, New Mexico, North Dakota, Oklahoma, South Carolina and Wyoming -- not so much.

Barbara

Wed, Feb 25 2015, 4:59 pm

notshanarishona wrote:

And so when the medical doctor tells a Jewish woman that she needs to be on BC for her health, and a rabbi disagrees, health insurance should not cover her pregnancy. And if she can't show cash on the barrel head, doctors and hospitals should be free to turn her away.

If she's told to eat on Yom Kippur, but fasts, then if (chas v'shalom) she goes into premature labor, or has a preemie, then insurance shouldn't pay. And the hospitals should be free to turn her away, even if it means the baby dies.

If someone elects not to vaccinate her kids, and the kids come down with a vaccine preventable illness, like measles, insurance shouldn't cover, and, again, unless they can pay cash, hospitals should be able to turn the child away. Even if she will die.

What about a woman with a difficult pregnancy. She's told it will recur, and she will wind up in the hospital for a substantial period of time. Why should insurance pay for her? She could use BC. And if she chooses not to, let her pay for the hospitalization.

Shall I go on?

Barbara

Wed, Feb 25 2015, 5:06 pm

Fox wrote:

I've definitely had it happen to me (as in me, not DS). Thank Gd for Urgent Care centers (associated with large physician groups, or independent) that can run a strep test or xray an ankle.

We use a very old-fashioned pediatrician who responds to all medical questions herself. But where its been more of a "look at this rash" than "fever! vomiting!" there have been occasions where we had to wait for an appointment.

chaiz

Wed, Feb 25 2015, 5:08 pm

Fox wrote:

* Why do ER visits involve such long waits? Not because of non-compliant patients. Rather, because physicians order all kinds of tests and treatments that are medically questionnable but can be used in a lawsuit defense. This happens not just in ERs, but in virtually any medical environment. Reforming malpractice claims would save enough money to adequately care for the most irresponsible bums -- but personal injury lawyers lobby hard against it.

Yes, defensive medicine is a real issue. But I just watched a video where the doctor/researcher was saying it is not like people are saying it. Some of it is a bit exaggerated. And you can talk about tort reform. But there needs to be a way that doctors are held accountable. Yes, mistakes happen do to humanity. But malpractice goes beyond human mistakes.

https://www.youtube.com/watch?v=ztFS23LtMzE

Last edited by chaiz on Wed, Feb 25 2015, 5:56 pm; edited 1 time in total

JAWSCIENCE

Wed, Feb 25 2015, 5:16 pm

If you have insurance the co pay for an office visit is significantly less than the co pay for an ER visit. If you have insurance you will got o the ER if 1) it is an actual emergency 2) You never bothered to get a primary care DR and your cardiologist can't exactly treat your foot ulcer, but the primary care guy and the foot ulcer specialist both don't have new patient appointments until next week or there are no primary care or foot ulcer guys in your area 3) your primary care provider is swamped (although they usually squeeze you in if you can handle the wait)

If you do not have insurance the reasons you will go to the ER are 1)the DR in an office can refuse to see you but the ER cannot 2) the DR may not have an appointment. The bill will be larger from the ER however the hospital has access to more charity care funds than a private office may be able to leverage. The hospital also might have its own collection agency, so take your chances on that one. You can try and get into a resident clinic which often gives great care and takes people with no insurance but those appointments are hard to get and wait times are often just as bad as the ER. Plus when you call in sick the sick/urgent appointments at resident clinic fill up fast and so they have a low threshold for sending to the ED, and they have no weekend/holiday hours (most private pediatrics and internal medicine practices have hours on one weekend day and holidays) so you get sent to the ED on those days too. For instance a newborn just sent home from the hospital on a Friday with instructions to see a Dr. within 1-2 days because the billirubin is high, but not high enough to need treatment will call the resident clinic and find out there are no sat/sun hours BUT they must be seen as the level can go up and cause brain damage so the person who answers the phone tells them.. go to the ER. For a blood test. A 2 day old newborn. So even the resident clinic who won't generally turn anyone away is not a total solution.

Freestanding urgent care clinics or minute clinics in pharmacy's often have short wait times and flat fees for those without insurance making them a great option for simple issues (but they don't exist everywhere! and most don't do billirubin checks or things like that.).

I know this is a digression, but I could not let the post stating ER visits are cheaper than doctors visits stand. An ER is hands down the most expensive place to receive your medical care in the U.S. The wait is not long because it is cheaper. It is long because they cannot turn you away while private offices can and access to care in this country is less than optimal.

My pediatricians office has never not squeezed in a sick kid. The only time you get told to go to the ED is when it is a Sunday and they cannot tell on the phone if it is an emergency (they have saturday hours but no sunday hours). On sunday you generally text the Dr. (yep, he takes text) and he'll call you back with a recommendation or tell you it warrants a visit to the ED. I have never had a receptionist tell me to give fluids and call back in a week if it doesn't work. That's insane and you should complain to the pediatrician/vote with your feet and go elsewhere.

ora_43

Wed, Feb 25 2015, 5:22 pm

questioner wrote:

Ora, I also pay a lot more to go to an emergency room than a drs office, and after 3 emergency room visits, the (formidable) price doubles. I would never just go to an emergency room because I couldn't get an appointment.

Right, if you're insured and make the payments, it's more expensive to go through the ER. But AFAIK for the uninsured it sometimes was/is the only option. IOW the issue isn't that the ER isn't expensive enough, it's that other options aren't always cheap/available enough.

eta - I see my previous post was really not clear, sorry. I didn't mean to say that ER visits are cheap in the states. I know from experience that that's not at all true. OTOH, I also know from experience that it's sometimes the cheaper option (when the alternative is paying for insurance).

Last edited by ora_43 on Wed, Feb 25 2015, 5:26 pm; edited 1 time in total

JAWSCIENCE

Wed, Feb 25 2015, 5:24 pm

chaiz wrote:

There's more to it than the price of extraneous tests. It is often the size of the judgements made that is the problem because malpractice insurance rates and legal fees are very high and Dr.'s must figure them into the costs of their services. Yes people should be held accountable but should someone have to pay millions of dollars because something that may or may not be a medical mistake occurred and a tender hearted jury decides to award 50 million? Other countries have caps on payouts and/or systems where the government actually covers malpractice (and the incentive to the Dr. is that after too many or too egregious mistakes their license can be in jeopardy). The price of extra tests is only a small part of this equation.

(not to mention look at plenty of imamother posts where someone posts their symptoms and aggressive posters tell them to refuse to leave the ED until they get such and such test that costs half million dollars because that posters cousin did not get the test and had to wait for two days before a correct diagnosis was made because the Dr. would not order such and such for an extremely rare condition on the first day.)

JAWSCIENCE

Wed, Feb 25 2015, 5:27 pm

ora_43 wrote:

Correct. Your initial post made it sound like you thought ERs were flooded because they were cheaper. This post is much more on target although the bolded still makes it seem like you think there is a scenario where the ER is cheaper. It is more expensive for both insured and uninsured to go to the ER however, for many it is the only available option.

ora_43

Wed, Feb 25 2015, 5:36 pm

JAWSCIENCE wrote:

I don't understand your last sentence. If it's the only available option to the uninsured, how is it not cheaper? The alternative is paying for insurance - no? A single ER visit can easily be cheaper than, say, 2 years of health insurance.