I didn’t become a doctor to bankrupt my patients

I didnt become a doctor to bankrupt my patients

I have come to terms with making difficult decisions.  I accept the possibility of committing a mistake that will cost a life.  But I never signed on to bankrupting my patients.   Never!

I had been up all night tossing and turning.  The stat CT scan was deemed unnecessary by the insurance company.  My patient called crying saying he couldn’t afford the thousands of dollars in charges.  Never mind the fact that the results suggested two life altering diagnoses.  Feeling horrible, I called the hot line immediately and was told that the consulting physician would not be available till the next morning.  Meanwhile, my patient was set up for an emergency consultation with the appropriate specialists.

My blood pressure began to rise the next day when my staff was still unable to reach the appointed doctor, the judge and jury deciding my patient’s economic fate.  I replayed the decision process in my mind.  Of course I could have done a chest x-ray and an ultrasound first.  But given the acuity of the symptoms, I didn’t feel like I could wait.

And indeed, the scan did exactly what it was meant to.  It answered the pertinent question and allowed for immediate, possible life saving, action.  But as I finally picked up the phone to argue my case, I felt my heart beating out of my chest.  If I didn’t perform, if I didn’t say the right things, my patient would be saddled with unmanageable debt.

My vocal cords shaking, I answered the questions as best as I could.  The businesslike voice on the other side of the line was steady and devoid of emotion.

But why a CT scan?

I again described how the acute shortness of breath, abdominal pain, and surprising physical exam mixed with the recent history of cancer was troubling.  I waited in between long pauses for a verdict.  Eventually, I was told that the interview was over.  Helplessly, I sputtered out the question that rested so heavily on my brain cells for the last twenty four hours.

So are you going to cover it?

Impatiently,  he explained that he wasn’t able to give me a determination over the phone.  The nurse coordinator would call my office back.  As the words left his mouth a female voice chimed in who, unknown to me, had been monitoring our conversation.

Thank you doctor for your time.

A few minutes later we received the call telling us that the CT scan would be covered.

This time.

I breathed a sigh of relief.  Now, I could go back to dealing with the fact that his life and health would never be the same again.  He was my next appointment.

It was time to break the news.I didnt become a doctor to bankrupt my patients

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.

Image credit: Shutterstock.com

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  • http://www.facebook.com/profile.php?id=662132748 Lata Potturi Schaedler

    It’s disgusting that you have to beg insurance companies this way. I’m so glad that the CT was covered and that you took the time to call and get it taken care of. I’m repulsed by the system.

  • drgg

    god that’s cold. We’ve all been there. Between the insurance and the patient they make it all our problem when it is not our problem to solve really. I so wish we had a strong organization or lobby like all the other industries do. I don’t understand why we don’t. i know I would contribute. The AMA has failed us in my opinion and others I think feel likewise. It would be so nice if we could lobby for ourselves.

  • http://www.cidpusa.org Dr Imran Khan

    Get the AMA and other associations out or docs will become their slaves

  • http://twitter.com/RHR_Chat RHR_Chat

    My query has always been to whom precisely the physicians’ ethical duty is
    owed (and in what order). (1) Medical institutions & medical practiced that employ docs have contracts with insurance companies. (2) Docs have contractual relationships with their employers. (3) Docs often have consultant contracts with medical equipment suppliers. (4) Docs have patient-physician relationship with patient.

    Doctors have conflicting fiduciary duties.

    drgg-Patients are between rock and hard place. We try to work with our insurance companies but they require info we can’t provide. That probably falls under the doc contracts with insurance companies. As pts, pour goal is to be compliant. We can’t be compliant if there are disagreements b/t ins and docs. It happened to me during cancer treatments and stalled my care.

    • southerndoc1

      “to whom precisely the physicians’ ethical duty is”
      As long as docs and patients choose to work with insurers, Magic Eightball will always answer “Situation Cloudy.”

      • drgg

        Well put. I think pt’s get stuck because they don’t want to have to be involved fighting for their CT scan when they are fighting an illness. Understandable.
        But patients need to think about this reality BEFORE they get sick. In general, they tend to sit back passively hoping some third party will come to their rescue when this is just not reality. Being passive in this system is a set up for disaster for the patients. And doctors alone cannot solve this problem for them.
        You can see that Dr. Grumet who wrote this article has actually given notice in his practice and is leaving in a year his practice. The more unnecessary pressure put on PCP’s, the more likely they will be leaving. A patient cannot expect that a doctor can rescue them from their insurance company.

  • Suzi Q 38

    Dr. Grumet did “above and beyond” to help her patient.
    Most of the time, I have to battle the insurance company on my own.
    Once, I had to threaten getting a lawyer (I didn’t really have one).
    Another time, I knew I needed an MRI of my knee to see how injured it was.
    The insurance company refused, and ordered physical therapy instead.
    I tried the physical therapy but it did not work.
    I could barely walk.
    It hurt so much that I decided to call the insurance company myself.
    I told them that I was going to get 3 bids for an MRI in the area that I lived.
    I picked a local hospital, who had the cheapest price.
    I told them that since they had always denied me what I really needed, I was going to get the MRI done tomorrow at 10:00 A.M.
    why???They asked. They did not approve it; I would have to pay and not get reimbursed.
    I told them I was so confident that there was a problem that I was going to get the MRI done anyway.
    I was going to play a “game ” with them.
    I told them this.
    I said: “If I have the MRI done and nothing is wrong, them I will “eat” the charge. Conversely, if I get the MRI and there is a lot wrong, I will sue you in small claims court and will probably win. If it shows that I am really bad and I need a total knee replacement because you have denied me care for the last 6-8 months, I may think about getting a lawyer for pain and suffering. Please make sure you boss knows what I plan to do tomorrow morning. what is your name?? May I please speak to your boss?”
    The boss spoke to me and said that I should wait a few days.
    I was in pain, so I refused.

    She finally called me back within a couple of hours and told me that I could get it at the same hospital and they would cover it.

    I hate having to deal with people this way, but I had no other choice.
    After that experience, I switched over to PPO.

    • http://twitter.com/RHR_Chat RHR_Chat

      But the patient goes to the medical facility and the physician because the insurance company has a contract with the facility. That contract is between medical facility-insurance company. There is, as such, a duty on the part of medical facility to deal with the insurance company.

      Best idea – stop contracting with unreasonable insurance companies. But this “glitch” is certainly no the responsibility of the patient to “unglitch.”

      • Suzi Q 38

        I did. I switched over to a different insurance company and went one step further…I signed up for PPO rather than HMO.
        I pay a lot more, but I have more flexibility.

  • http://nhsvault.blogspot.com Richard Blogger

    As a patient, when you are feeling ill with the threat of a serious treatment, the last thing you want is to worry about the cost: you just want to recover. I’ve been in that situation. I live in England where no one is ever bankrupted over medical bills. Doctors still make resource decisions – particularly when there is doubt over whether the intervention will be clinically effective – but not of the level described here.

    However, I am scared. The NHS is cost effective, but under the current government it has been allocated the same budget (in real terms) for the five years 2010 to 2015. Imagine that, no real terms increases in healthcare costs for five years, is that possible in the US? There are doubts if it is possible in England. The government’s austerity is making the economy worse and, as a nation, by 2015 we will borrow £238bn more than planned. The government’s response is to extend the English NHS flat funding for at least another two years (to 2017) or even to 2020. A decade with no real terms increases. I fear that the response will be co-pay and I will see blogs like the above written by patients in my own country.

    • drgg

      too bad and i was hoping to move to England. but seriously, i saw an article in the New york times about how American drug companies Johnson and johnson was one of them—are overcharging for meds in the NHS that is making things untenable. At least you guys are fighting back. Over here the government gives them whatever they want to charge. Thank god you push back there. I AM SURE THERE ARE OTHER REASONS FOR HIGH costs over there but that is one factor i just learned.

  • Docbart

    Good for you for fighting. I have had to do this by phone or by mail, sometimes appealing adverse decisions. I like to ask the reviewing doc to spell his/her name so I can record it in the chart. Deprive them of anonymity. If there is an adverse outcome because of a refusal, they know that they are potentially on the hook. I also record on the chart the time I wasted on the endeavor. Next visit sometimes gets an upcode. Let the insurer pay a penalty for their own avarice.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Brilliant!!!!

  • sleemd

    As physicians, we’ve all been through this . . . every doctor dislikes having decisions scrutinized. However, the reality is, with the unsustainable growth of healthcare costs, physicians are going to be asked more and more to substantiate the value of treatment decisions.

    For many advanced diagnostics, there are evidence-based guidelines published by professional societies such as the American College of Radiology that can be solid foundation for pushback when decisions come into question. There are also evidence-based guidelines for the management of clinical symptoms published by societies such as the American Academy of Orthopaedic Surgeons. There are more and more evidence-based guidelines published after tedious meta-analysis of the existing body of literature by credible sources, i.e. our professional societies. These guidelines are intended to protect our decision-making and our practices.

    • southerndoc1

      “the unsustainable growth of healthcare costs”
      When the insurer has a contracted rate with the hospital for CT scans that is 400% of what the freestanding facility gets paid, I quickly lose interest in trying to save them money.

  • disqus_En6rJ88A7A

    I admire the effort and concern for the patient…But the case you picked to discuss is of course one where the patient definitely needed the CT and the medical justification was quite obvious…Makes you look so right. I wish you had picked the much more typical case where the CT we order is a medical judgment call… say the elderly patient with nonspecific mild to moderate abdominal pain that could be something quite serious but then thankfully turns out to be nothing serious. In these much more typical cases the insurance co. doctor has a review field day.