Comments on: Paying cash to doctors affects the treatment plan

By: Med Humanities

Med Humanities — Thu, 29 Jul 2010 20:22:17 +0000

After having xrays for another problem, my internist reported the results (negative) and mentioned that the radiologist noted some spinal stenosis & recommended an MRI. Since I have little or no discomfort from the stenosis, and was not planning on doing anything about this “incidentaloma,” I refused the MRI. It should be noted that I am fully insured and it wouldn’t have cost me a dime.

By: Alina

Alina — Wed, 28 Jul 2010 00:48:18 +0000

Max – I don’t recall putting the blame on the patient.
You said “Wait a second, you are saying that when patients spend their own money, they are more judicious with how it is spent?”
Alina – With this statement you’re suggesting that when patients don’t pay the bill, they just don’t care about how much the tests cost. Anyway, that’s just not the case. You’re basing everything on the cost, but as a patient is that the only thing you consider? Not all tests are without risks you know. Some can actually do more damage and if they are unnecessary, would you go for it?
Max – And you are presenting a false dichotomy by pigeonholing physicians into either “prescribing what they should” or ordering extra tests “just to make a buck”.
Alina – When a physician recommends a test that even the patient knows is not necessary then we can’t really say it is done “just to be safe.” PCP said was puzzled by recommendation, specialist second that and an overseas physician was able to correctly diagnose patient via a mere telephone conversation. That to me sounds either like pure incompetence on the part of the recommending physician (which had many years experience) or he did it to make more money (the facility would have benefited from performing more tests, quite costly I may add). Guess what, it wasn’t about the money as the patient’s insurance would have covered everything. So, I stand by my initial post when I said that some physicians are really good, while others are quite the opposite (for different reasons).
Max – “Did it occur to you or anyone else why the doctor spent 45 minutes with the patient? I’m quite sure it was not out of charity or goodness so much as it was the fact that the doctor was actually paid for his time.”
Alina – Okay, this one is really funny. Since you brought it up, why did the allergist spend 45 minutes to diagnose a sinus infection? And how much does it take to Rx an antibiotic for this? Further, the author says that the allergist is an acquaintance, former attendant to be exact. So Jay pays the allergist $150 so they can go down memory lane and probably make small chat. I do that with my friends and acquaintances for free! Seriously, now, would you pay $150 for a sinus infection diagnosis? Where is the value in that? That could have been done in 5-10 minutes.
As I posted a few days ago my PCP spends 30-40 minutes even with Medicaid patients and he gets paid by the same formula as the rest of his peers (I know, I know some states pay more than others, but he’s not in a top-paying state). Some insurance companies also have quite liberal fees and spend a pretty penny for a longer visit.
Max – If a patient is paying cash, then I can charge a fee that adequately covers my cost. I am going to want to keep that patient coming to me, so I am going to take extra care that the patient feels that they are getting their dollar’s worth. I am going to arrange my practice so that I can be as efficient as possible, and at the same time, giving the patient the time and care they are paying for.
Alina – Interesting. So for all your patients who are covered by an insurance plan, do you tell them upfront that you would not give them all your attention, and in fact they will receive suboptimal care b/c they are not paying you cash?
Max – At the same time, the patient is going to judge the quality of care, my use of their time, and the services I offer, and make a decision as to whether they want to continue to utilize my expertise.
Note that these are not foreign ideas. These are the principles employed during practically every single business exchange. Yet they are completely foreign in medicine. Why is that?
Alina – Incidentally I know a thing or two about business strategy. The whole thing with all doctors going into cash-paying practices, as it’s being suggested all the time, I can tell you that it will never happen – for a series of reasons. I’m not going to go into business strategy now (nothing is free, right? ), but will tell you that first and foremost, a provider or manufacturer has to always consider the customers, their willingness and most importantly ability to pay. The market would never support such a model, especially in these current conditions. Not all of us live in the Hamptons, you know….
If you are a physician and you take all forms of payment, you have a duty to serve all your customers the same, unless you disclose upfront that your services and the amount of effort you put in will be different depending on their payment form. I suspect that’s not the case.
If you want consumers to chose then you also have to offer price transparency. Right now, not even the walk in clinics where they expect you to pay cash don’t advertise their prices. I never understood this concept where you’re expected to sign your life away without knowing exactly what you’re going into.

By: Max Power

Max Power — Tue, 27 Jul 2010 02:37:29 +0000

@ Alina.

I don’t recall putting the blame on the patient. And you are presenting a false dichotomy by pigeonholing physicians into either “prescribing what they should” or ordering extra tests “just to make a buck”.

Nobody is disputing that health care is not as efficient or cost-effective as it could be, but the reasons are more complex than doctors being greedy.

Because virtually all health care costs are paid by a third party, neither the patient nor the physician have any emotional attachment to the cost of the services. Neither of them have any real incentive to restrain the amount of treatment delivered.

You and others can argue that physicians should just exercise self-restraint solely out of their sense of ethics. It would be nice if they did, and maybe all our woes would be solved. But it still remains that despite the efforts of all the talking heads and finger waggers, doctors still order numerous tests “just to be safe”.

Did it occur to you or anyone else why the doctor spent 45 minutes with the patient? I’m quite sure it was not out of charity or goodness so much as it was the fact that the doctor was actually paid for his time.

If a patient is paying cash, then I can charge a fee that adequately covers my cost. I am going to want to keep that patient coming to me, so I am going to take extra care that the patient feels that they are getting their dollar’s worth. I am going to arrange my practice so that I can be as efficient as possible, and at the same time, giving the patient the time and care they are paying for.

At the same time, the patient is going to judge the quality of care, my use of their time, and the services I offer, and make a decision as to whether they want to continue to utilize my expertise.

Note that these are not foreign ideas. These are the principles employed during practically every single business exchange. Yet they are completely foreign in medicine. Why is that?

By: Alina

Alina — Mon, 26 Jul 2010 22:37:47 +0000

DocD and Max – why is it always the patient that’s being blamed? Why doctors never really look at their colleagues to see that not all are “created equal?” Who is really the Subject Matter Expert, the patient or the doctor?
Shouldn’t the doctor be responsible for recommending the appropriate treatment? As a patient I’ve experienced both sides – doctors who are responsible and prescribed what they should and others who order unnecessary tests just to make another buck. It’s all about ethics and respect for self (as a doctor) and for the patient.

By: Max Power

Max Power — Mon, 26 Jul 2010 15:31:12 +0000

Wait a second, you are saying that when patients spend their own money, they are more judicious with how it is spent?

Your suggesting that physicians, when they are face to face with the economic impact that their treatment decisions cause, they find ways to boost the value of their patient’s dollar?

This sound suspiciously like a free market to me. And we have all been told that the free market just doesn’t work. Right?

By: HJ

HJ — Mon, 26 Jul 2010 14:52:48 +0000

It’s interesting you contribute the quality of your care to paying cash and not to the fact you are a doctor. In this article you imply that doctors don’t offer patients appropriate health care for financial reasons. As a patient, if I were to say something like, “My doctor cares more about his bottom line than my health,” I would guess I would be heavily criticized.

One thing that keeps my away from the doctor’s office is the feeling that I will get nothing out of the appointment if I don’t want an array of tests. Perhaps it only seems that patients want every test available because those that don’t want testing, don’t come see a doctor.

By: Margalit Gur-Arie

Margalit Gur-Arie — Sun, 25 Jul 2010 22:25:00 +0000

The only thing I find astounding about this visit is that the doctor spent 45 minutes talking to you. 45 minutes!! Maybe if everybody got 45 minutes for an allergy visit, we would save billions in unnecessary tests.

And good thing the doctor wasn’t using electronic prescribing. Otherwise you wouldn’t have been able to get that great deal on Augmentin.

By: Wade

Wade — Sun, 25 Jul 2010 22:24:42 +0000

I live and work in Thailand where the vast majority of people do not have medical insurance of any form and it is all cash, pay for service. You see some ingenious ways caring doctors sort out the issue even to the extent of one friend of mine actually being paid with the gardening at his home being done and a chicken for dinner. Very old school.

By: Doc D

Doc D — Sun, 25 Jul 2010 22:24:05 +0000

The lesson here can be generalized to all health care systems where patients do not have to make judgments about value. I ran a hospital some years back which provided free care to beneficiaries. I was always getting beat up for a utilization rate 1.8 times the general population (our patients were comparable: socioeconomic, co-morbidity, etc). That is, our patients sought care almost twice as much. Patient surverys said that they over-used the sytem because they could, and because it cost them nothing. The doctors had no incentive to keep costs within what patients absolutely needed, because it cost the patients nothing to do the “nice to have” tests. Somebody else paid for it (the American taxpayer actually). Reformers had all these ideas about nurse triage 800 numbers, refill appointments, encouraging self-help, elminating OTC from our pharmacy, etc. None of that worked (but it never stopped them from coming up with new plans).

Any doctor who sees fully subsidized patients (either Medicaid, or no deductible/no co-pay insurance) has had the experience of looking at a patient chart before entering the examining room and seeing, “Chief complaint: wants Tylenol prescription.”

I’m all for insuring access to care, but with perverse incentives, we will have trouble funding it.

By: Max

Max — Sun, 25 Jul 2010 22:23:16 +0000

How dare you. You suggest allergists do more tests simply for money (including your friend by implication) and yet here you are, a pediatrician, making $5000/month loan payments, living in Manhattan? Are you kidding me? Here I thought pediatricians averaged about $80k/yr. I’ll bet your allergist friend wishes he could afford a $5k loan payment per month. If you let this go unchallenged, Kevin, you are no true blogger.