Healthcare needs to be simpler and more like real economics

A middle aged patient whom I have seen in the past for benign palpitations called today because of atypical chest pain. Although I have criticized the overuse of nuclear imaging studies, and probably order the fewest of any cardiologist in the city, there are times when they are appropriate –this was one of those occasions. Symptoms did not rise to the level of an invasive angiogram, but could not be ignored either. Further diagnostic testing was needed.

How do I know it was appropriate for this patient? Because I called her, took a history, and assessed the situation. The history of present illness, past medical history, risk factors and essentially all the information needed to decide on further testing was available with 20 minutes of time and a phone. A side bar in this case is, unlike my law colleagues, the one-third of an hour of time spent was free.

To my surprise, a few minutes later my medical assistant informs me her insurance will not authorize the stress test until she is seen in person. Really?

This patient will have to come in and see me. I will take the same history. The examination will undoubtedly not change anything (it was normal last year), and I will order the same nuclear stress test. Now, the bill will include a bill for an office visit, an ECG and the stress test. If my partner in my new cardiology group saw the patient, it would be a new patient visit, ECG plus stress test. An extra two hundred dollars in billing plus the inconvenience to both patient and doctor arises from this silliness.

What should have happened in this case? The patient comes in for the stress test, the supervising doctor gives a preliminary read of the stress ECG, and I would have called her the next day with the imaging results.

It is dumb, inefficient and borders on the anger-inducing to have an uninformed profit conflicted corporation making decisions on patient care that in this case increased the cost of care. Did the insurance company have a previous doctor-patient relationship, or did they discuss the symptoms with her?

Always pointing out problems, and never suggesting solutions gets old, so I will not perpetually drone on about the inadequacies of our present day delivery system.

To me, good answers usually come in simplification.

I am often slow to understand things, so someone explain why paying an internal medicine doctor, cardiologist or surgeon cannot be like the treatment plan for my root canal specialist — in which he swipes my credit card for $950 for a 45 minute procedure. No business office, no rejections of payments and no uniformed constraints are placed on the endodontist. Yes, it seems expensive, but the tooth hurt, then it didn’t, and he went to school, studied hard and learned an important skill that enhanced my life.

Yes, I know health care costs for hospitalizations get catastrophic quickly, so obviously there is a role for insurance of some type. I get this. But why does 93651 — the code for catheter ablation — which takes longer than a root canal to do, way longer to learn, and is far more dangerous to the patient pay $300 less? Additionally, cardiologists have to hire a business office to file the paperwork, and appeal the frequent rejections.

Seems that a starting point would be to make healthcare more like real economics.

Also, like I learned by paying $950 for a preventable dental problem, patients who pay the doctor with a Visa card are surely more prone to discover the benefits of healthy living behaviors.

I better stop.

John Mandrola is a cardiologist who blogs at Dr John M.

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  • anonymous

    just to quibble, since you already have a relationship with the patient, likely you would not get a consultation visit, just a follow up visit. ditto for your partner in the group, even though they have not treated the person. it might actually be cost effective for the insurers for force you to see the patient since they might not show up (saving the cost of the stress test), and if they do show up, maybe the pain has gone away and no testing will be done for the $50 they have to pay for follow up visits.

    • stargirl65

      He would not get the consult visit since he has seen the patient before, the patient initiated the visit, and he is primary care ( who rarely do consults plus Medicare won’t pay consults anymore anyway). His partner is in a different specialty so can charge a consult (if not Medicare) visit or a new patient visit even.

  • Derm

    Guess what? You can change this! It may be hard at first with less income, but think about the amount of time and staffing charge Iu will save. I plan to charge pts at time of service much like my wife who is a dentist. Them the pt can apply for reimbusement. I think insurance would be much more responsive to pt anger than physician anger as they pay the premiums

    • Surgical resident

      Much easier forna dermatologist to do this then a cardiologist.

  • Mark McAllister MD

    A – men!

  • SusanH

    In Democracy, majority rules…
    Doctors MUST be murderers, profiteers, or fools.
    So illegalize doctors, and by inference nurses, (EMTs,) and medical schools;

    Lawyers and Insurance Employees, only These Few,
    Should proclaim what is Appropriate Standard of Care
    And we all must live and Die within Their Purview,
    As Their judgment has been deemed by U.S. To be Fair.

  • bw

    I’m a third year medical student, and I have to say that you all have inspired me to consider a career in primary care. I have this little fantasy now of starting a small cash-only practice where you could afford to see 12 patients a day, at 30-45 minutes a visit because of the low overhead, charging a flat fee for the time spent counseling, and give transparent pricing of tests with no additional fee to interpret them (because my time will already be paid for). I would also seriously invest time into learning what is now the vanishing art of physical diagnosis, because it seems to me to be the single best way to cut expenses in this country. Now if there were just some legal protection for this attempt to practice cost-conscious medicine…

    Of course, I don’t know how feasible all this is. I’m just a student. But I think about it…

  • jsmith

    “I am often slow to understand things, so someone explain why paying an internal medicine doctor, cardiologist or surgeon cannot be like the treatment plan for my root canal specialist — in which he swipes my credit card for $950 for a 45 minute procedure.”

    If you are willing to do a little reading, Nobelist Kenneth Arrow explained why way back in 1963. Curious how otherwise well-educated physicians are innocent of this analysis. Medical care is not like other commodities, or even like the (relative to medicine) simple field of dentistry. When you buy a loaf a bread or go in for a toothache, you can pretty much figure out on your own if it’s a decent deal. Not so with medical care. It is characterized by lack of predictability (hence insurance, either private or government) and informational asymmetry (hence professional standards and outside monitoring).Here’s the link:

  • Ed

    recently paid near $1000 for a routine maintenance service on a family Subaru. Americans spend more on transportation than on health care. Certainly deductibles in the range of HSAs are workable and more affordable in the big picture.

  • Max Power

    People will drop thousands of dollars on dental work, electronics, automotive repairs, cell phone bills etc. without batting an eye. Suggest that someone pay more out of pocket than a $20 co-pay and you better be prepared to face the righteous indignation of the people as they pray for the hand of God to squash your blasphemous soul!

    Doctors need to stop being such wimps and stand up for themselves. We are not clergy, we are professionals who deserve to earn a fair wage for our skills.

  • Duncan Cross

    Dr. Mandrola:

    Private health insurance actually is “real economics” – the fact that it sucks is an argument for single-payer care. But if you still want “real economics”, we should start by ending state-enforced physician licensure, and let the market decide who is qualified to practice medicine.

    As for dentistry, you should look up the name “Deamonte Driver”; a lot of people think dentistry should be a lot like the rest of health care, not the other way around.

  • Molly Ciliberti, RN

    Not everyone drops thousands of dollars on dental care or their car; there are millions who have aching teeth, no car and only option for health care is to wait until half dead and then head for the Emergency Department. We need universal healthcare like the Swedes, Danes, Finns, etc. This is something the government can do well and people will get taken care of and physicians will be paid.

    • BobBapaso

      No, health care savings accounts for everyone, subsidized if necessary. Then you and your doctor would decide how you were treated, not the government or an insurance co.

      We need licensure, but a better way to determine who is competent to have one. People lie, and I don’t want to be treated by someone who went to medical school, but didn’t.

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