How to save hundreds of dollars on your medical bills

How to save hundreds of dollars on your medical bills

Rob got a cat bite. Then a swollen hand. He goes to the ER, gets antibiotics, then develops itching. So he calls me for advice.

A few days later, I get this email: “The itching from the antibiotics went away as you said it would. But what is NOT poised to go away is the $624 bill from the ER for talking to a doctor for 5 minutes. No blood drawn, no stitches made, no x-rays, but I’m told the standard amount for the classification of my visit is $624. I called to complain and, of course, the person on the phone can’t do anything. Well, she could have sounded sympathetic. I didn’t even know that there’s a difference between an urgent care and an emergency room. Apparently, an urgent care would have been cheaper. Where is there an urgent care downtown?”

Urgent care is just 2 blocks from the ER. But why didn’t Rob just call me? He wasn’t sure. Why do so many patients like Rob end up in the emergency room with non-emergent conditions? Let’s think this through.

An emergency is a serious, unexpected, and often dangerous medical condition requiring immediate action such as a heart attack or gunshot wound. An urgent medical condition is a very important, but non-life-threatening situation that needs immediate attention such as a dislocated shoulder or kidney infection. A routine medical condition is neither urgent nor emergent such as high cholesterol or hemorrhoids.

Let’s say I’m your family doctor. It’s Saturday morning and your kitty bites you. Your hand is suddenly red, hot, and swollen.

Should you go to our 60-room, 44-bed, 30,000-square-foot emergency department and trauma center that includes a waiting area with a fireplace and a children’s playroom? Do you really need 2 psychiatric holding rooms, 2 trauma suites, and a decontamination room with a dedicated entrance for patients exposed to hazardous material? Upon arrival you may be treated by up to 4 doctors and 17 nurses, all emergency-trained and you’ll have 24-hour access to anesthesiologists, neurosurgeons, and all manner of specialists.

In case you need to arrive by helicopter from the 8-county service area, expect to enter an extra wide mega-elevator that will enable your continuous care during transport from the hospital’s rooftop helipad. By the way, if you need this level of care, please call 911.

Or should you go to our 6-room, 3,000-square-foot urgent care that staffs one family doctor, a nurse, and a medical assistant? They do x-rays and labs and they’re open from 9:00 am until 9:00 pm every day with six locations in town.

Or should you call me? I work in a cozy 280-square-foot clinic. I have no staff. I handle urgent and routine conditions and perform minor surgeries. Once, I even removed metastatic lung cancer from a guy in my office. I work most afternoons, but I’m available 24/7 for urgent needs. Best part: my low overhead allows me to pass savings on to you. How can I do this? Watch my TEDx talk.

Today Rob sends another e-mail: “In addition to my initial fee of $624 associated with my cat bite, I got a second bill for $194.70. It’s totally different looking and is from the emergency physicians. The bill references a nurse practitioner. I suppose I never actually saw a physician.”

The truth is: you could get treatment anywhere for your cat bite. The real question is: how much do you want to pay for it?

Emergency room: $818.70.

Urgent care: $99.

My office: $50.

Your choice.

Pamela Wible pioneered the community-designed ideal medical clinic and blogs at Ideal Medical Care. She is the author of Pet Goats and Pap Smears.

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  • http://www.prescriptionassistancenetwork.com/ Drew Golden

    Pamela, there do seem to be plenty of people who don’t even know that there are alternatives to visiting the Emergency care facility. And those who do know have trouble classifying whether their situation is ‘urgent’ or ‘emergent.’

    • PamelaWibleMD

      Yes! It is amazing to me (from the physician side of the fence) that patients are unaware of the facilities in town and also that they have no idea whether they are having an emergent or urgent need. I’ve been called in the middle of the night for constipation (not urgent –> routine) and Ive had a woman show up for a routine visit with a skin cancer eroding her entire left side of her face (not routine –> urgent).

      • PamelaWibleMD

        Sometimes what happens is that an urgent problem leads to anxiety and panic. Then the patient feels they are having an emergency.

  • Patient Kit

    I must ask: Why and how did you remove metastatic lung cancer from a guy in your office???

    • PamelaWibleMD

      The story is chapter 96 in my book Pet Goats & Pap Smears: http://www.petgoatsandpapsmers.com (can read part of it for free on Amazon)

      • PamelaWibleMD

        But essentially a guy hitchhikes to my office from 3 hours away. He shows up with painful nodules all over his back and face. I excise a smaller one near his shoulder to get a diagnosis: metastatic adenocarcinoma of the lung.

        • Patient Kit

          Thanks very much for the explanation. That which I was previously having a hard time imagining, now makes sense. :-D

  • NormRx

    i am in a Medicare Advantage HMO. I recently had an arthritis flair up, it came on very quickly from no pain to severe pain in my right leg all in the matter of about three hours. I could not put any pressure on my right leg the pain was so severe. I though I might be suffering from a deep vein thrombosis so I went to urgent care. The urgent car doctor agreed with my self diagnosis so he ordered an ultrasound, he gave me a shot of cortisone and a script for five days of prednisone in case it was just an arthritis flair up. Well, it was not a DVT, it was an arthritis flair up and in about five days the leg was back to normal. My insurance company rejected the total claim because they said I should have gone to the emergency room instead of the urgent care center. So now I am looking at a $377.00 bill for five minutes with the urgent care doctor and a shot of cortisone and a $500 ultrasound image. I though I would save the insurance company money by going to the urgent care center instead of the ER. As the old saying goes “no good deed goes unpunished.”

    • Lisa

      If the urgent care you went to was part of your network, you really should contest your insurance company’s decision.

      • NormRx

        That was the problem, I was in an HMO and 1500 miles from home. When I purchased this plan my agent said when I was out of town I could go to an ER or urgent care. Not true, the plan only covers the ER when I am out of town.

        • Patient Kit

          That really is another mystifying layer of the insanity that is our healthcare system — that your insurance covered the far more expensive ER but not the less expensive urgent care center. I can see why the hospital, from their revenue stream POV, would prefer you in the ER. But the insurance co? Crazy stuff.

          • SarahJ89

            Not a mystery, really. The insurance company wins because it pays NOTHING this way. It only lacks logic if you’re looking at it through the lens of actually providing coverage. The game for insurers is to make money not only by taking our health care dollars and investing them while providing NO service, but to figure out ways to deny claims whenever possible. They get to pocket that ER claim this way.

            I would definitely go back to the agent and perhaps to my state’s Commissioner of Insurance since the customer was basically lied to about coverage.

    • PamelaWibleMD

      Contest this with your insurer.

      • NormRx

        I am, but like I said, the plan only covers the ER when I am out of my normal service area. It really is my fault since I did not read the plan fully and I relied on my agents advice. I am asking them to pay the in network charges that they would normally pay and since I went out of network I will pay the difference. The purpose of my post is, insurance companies are driving people into the ER instead of an urgent care setting. I don’t understand this, since an ER visit cost more than an urgent care visit.

    • Gibbon1

      “a $500 ultrasound image”

      Want to guess how much ultrasound machines cost? Less than a new car. Depending any wheres from $1500 to $15k. Unless you go really high end, then maybe $40k.

      Wanna know how much it costs to rent a new car? $40-60 a day. That’s day not 5 minutes. Use of equipment like that should be part of the price of the visit not billed separately.

      • PamelaWibleMD

        Everything is charged separately. Especially in the hospital setting. How can they otherwise cover their astronomical overhead? Many patients are still uninsured and others are on poorly-reimbursng government insurance. So . . .?

        • Gibbon1

          That’s the point, the $500 ultrasound is the accountants shoveling losses into your patients bills. Historically ultrasound machines used to be incredibly expensive. Not true anymore, what’s left is shady legacy pricing.

          Seriously in my office right now I’ve access to equipment that cost $150 grand new. if i need any of it for my work I just use it, we’d never think of charging a separate fee.

          • PamelaWibleMD

            What kind of work do you do Gibbon1? Are you getting paid through third-party payers who reimburse poorly? If so, you need to make up the difference somehow. Right?

          • Gibbon1

            I’m a semi-feral consulting engineer. And dear old mom was a CPA specializing in small business audit. So I’m somewhat aware clients often pay late, not at all, or not in full. You’d think large corporations would always pay and on time, but you’d be wrong. Clients can also promise business and then not deliver. Clients representing companies can make promises that they don’t have the authority for. And 100% when that happens your SOL. And on occasion I’ve had to continue to support non-paying customers for a variety of reasons (usually because I’ve noticed that we’re wearing the same noose)

            A problem with $500 ultrasounds is the hospital is using tricks to hide the true costs of things from not only patients, but itself. When you do that, you end up unable to do proper cost analysis Thus hemorrhage money in all sorts of unexpected places. As in ‘well we make a good markup on ultrasounds so we can afford top end machines instead of a more economical ones’. The difference is money down a hole.

      • Lisa

        One thing to remember is that you don’t get a driver when you rent the car. Someone, a tech usually, has to actually do the ultrasound and some one has to interpret the results.

      • Bill Viner

        You have a much different definition of “really high end”. 4D US machines can easily be over 100k. I’d hate to see the machine that you could buy for $1500. Resolution is expensive.

        • Gibbon1

          Might want to match your prices for this decade.

      • NormRx

        It was billed as two different ultrasound images for two different areas of the leg. I had a very nice tech and it took about 45 minutes to do the procedure and it had to be read by a radiologist. I wasn’t too clear on my post, my complaint was with my insurance company wanting me to go to the ER instead of an urgent care clinic.

        • Suzi Q 38

          The problem with the ER is the wait time.
          You would be triaged and put on the “slow” list…
          You could be there 6 or 8 hours.

          • PamelaWibleMD

            They do have wait times online at the website in my town at least.

          • PamelaWibleMD

            Again, if you are checking wait times you may not have a true emergency,

      • NPPCP

        Go buy an US and then try to utilize it when something goes wrong with your body. Heck, if they are so cheap, buy three of them. That is the TRUE cost of the machine – the expert behind it using it appropriately to find your problem and the other expert reading those findings to possibly save your life. In my opinion, your example is a poor one.

        • NormRx

          You are absolutely correct. I had a great tech and they provided me with a DVD of my ultrasound image. It was really interesting, even though I didn’t know what the hell I was looking at.

          • PamelaWibleMD

            Always have to explain to patents who bring me their CTs on DVD that I have no idea what I am looking at. thank God for radiologists. I don’t know how veterinarians do it all.

    • Suzi Q 38

      Thanks for this reminder.
      If the urgent care is not part of the insurance plan, we are out of luck.
      I do have PPO insurance, so I think even the urgent care centers are covered.

    • Sheila Swan Lafuer

      Pamela Wible you are clearly a life saver AND a money saver. How wonderful to have you in our town! Your diagnosis of my everyday exhaustion was absolutely correct and within days of taking the vitamin you suggested all symptoms were gone. Thank you so much!

  • Lisa

    About once a year, I get a nice postcard from my insurance company, suitable for posting on the fridge, that reminds me of the alternatives to the ER. It notes that my pcp’s office has a doctor on call, who will return calls outside of office hours. It also gives the number of a nurse hotline, as well as the location and hours of urgent care clinics I can go to.

    I’ve never needed the information because I have always been able to see my pcp during office hours, on the same day, if there is an urgent problem.

    • PamelaWibleMD

      You’ve obviously got a great doctor. :))

      • Lisa

        I like my pcp and the way his practice (a group practice) runs.

        The practice keeps a bank of time for same day appointments. If my pcp isn’t working when I call with an urgent problem I have been able to see one of the other doctors on the practice that day.

        • PamelaWibleMD

          That’s service! Kudos to them. And great choice for your care. They get it.

  • PamelaWibleMD

    Ok. So a friend who works in the ER reminded me that price transparency is nonexistent in the ER. True. . . but . . .

    My response: If you have a true emergency and you need the helipad and the decontamination room, then you are not really in the mood to price shop. The problem: If you are doing a price comparison then DO NOT GO TO THE ER!!!

    You probably do not have a true emergency . . .get it?

    • NormRx

      Pam, One medical question for you. Do you think cat bites are worst than dog bites. I am not talking about trauma, but infection. My mother worked for a vet and she was bitten a number of times and she always had more problems with cat bites than dog bites.

      • Anne-Marie

        Dog bites tend to involve tearing of the skin and deeper tissue trauma – often a lot of bleeding that can wash away bacteria, vs. cat bites that are more like puncture wounds that seal in bacteria. There also seem to be some differences in the types of bacteria inside a cat’s mouth vs. inside a dog’s mouth.

        (I used to date a veterinarian!)

        I’m sure Dr. Wible can add her expertise.

        • PamelaWibleMD

          Agree with Anne Marie I have priorly seem infections in cat bites.

      • PamelaWibleMD

        Yes!

      • buzzkillersmith

        Cat bites are high risk. They are worse than dog bites in terms of infection. See eqvet above. The standard of medical care is that penetrating cat bites should be treated with preventive antibiotics, preferably within 6 to 12 hours or so. They also require close follow up. I see these pts daily until it is clear things are clearly improving. They usually clean up quite smartly with antibiotics.

        Sometimes I will just watch dog bites but always treat deep bites or crushing bites. Interestingly, human bites are bad like cat bites and should be treated with preventive antibiotics.

        If the bite occurred at 9 pm and the pt’s doc’s office didn’t open for another 12 hours, going to the urgent care or ER is the thing to do. A cat bite can blow up in 12 hours and you can wind up with purulent teno-synovitis in the hand, requiring the orthopedist to slice your hand open. Bad deal. I’ve seen it happen.

        But 600 bucks for wound irrigation and a prescription for 7-10 days of Augmentin is a bit much.

        • NormRx

          Thanks for the info Buzz. My mother always experienced a more severe infection from a cat bite versus a dog bite. I must either have a very good immune system or just lucky. I lived on a farm for some time and I have been bitten by feral cats and several times by dogs. The dog bites were never severe but in all that time I never had an infection from either the cats or dogs.

        • ethanspapa

          Puncture wounds would respond well to soaking the affected area in a little bit of bleach and warm water. If redness pain or swelling increased it would be time for a sick visit to the family Doctor.

          • PamelaWibleMD

            Yup!

  • http://debtconsolidationcare.com/ Phil Bradford

    On a different note, why doesn’t the local authorities step in and take care of this issue in a better way? I’m forced to ask – why would a cat bite warrant a costly emergency or urgent care? Things like these happens every now and then, and since childhood we’ve been hearing that we need to wash the wound with a soap under a tap. It just requires first aid and one can surely get treated at more relaxed pace. So why hurry?

    • Lisa

      Cat bites can get infected, which sounds like it happened in this case.

      One of my friends got bitten by her cat. The bite was bad, possibly requiring stiches, so she went to her doctor, who was required to report the bite to the public health departement. The public health department contacted my friend to make sure her cat’s rabies shots were up to date.

    • PamelaWibleMD

      In this particular gentleman’s case he developed rapid swelling and redness and the ensuing anxiety led him to seek emergency room services.

    • Anne-Marie

      Cat bite = high risk of infection, partly because of the bacteria that naturally populate their mouths but mainly because of their long sharp front teeth, which essentially inject bacteria deep into the bite wound. Soap and water help clean the skin surface but don’t necessarily do much for deeper bites.

      It sounds like this gentleman was unlucky enough to sustain a deep bite that then got infected.

      There was a study that recently came out on this very topic:

      http://www.usatoday.com/story/news/nation/2014/02/09/cat-bite-hospital-stay/5276997/

    • eqvet2015

      Phil Bradford: I’m not a doctor, I’m a vet student, but cat bites are a serious occupational hazard in my profession. Like other species, cats’ mouths have multiple pathogenic bacteria
      living in them, including Pasteurella spp., Capnocytophaga spp., Bartonella henselae, and various other aerobes and anaerobes. They
      have sharp, conical teeth that can penetrate deeper structures while leaving
      surface wounds that appear quite small. A deep puncture can cause anything from painful cellulitis that develops
      within hours to joint and tendon infections that require surgical
      washout and threaten the person’s ability to ever use their hand
      normally again. I don’t know anyone who’s been permanently disabled, but I do know
      people who have been unable to work with their hands for weeks to months after bad cat bites.

      That said, there’s a world of difference between “kitty brushed me with
      her teeth and made me bleed a little”, which is probably the majority of
      cat bites, and
      full-thickness puncture wounds from a cat’s canine teeth. The former is usually fine with first aid unless the patient is immunosuppressed or splenectomized; full thickness bites may not require a helipad but they do require prompt evaluation – not
      emergent, but urgent, especially if the bite is on the hand (like many
      are, since that’s the closest thing for a peeved cat to grab). Depending
      on the community and the responsiveness of the primary care doctors, the ER may be the only place to obtain timely evaluation and
      treatment if the bite occurs in the evening or on a weekend (multiple
      sources recommend starting antibiotics within 8-12 hours for deep bites or those on the hands), but I agree with the overall principle that treatment should be acquired in the place with the least overhead and lowest prices possible.

      • Lisa

        I think I am learning more than I ever wanted to about cat bites…. ;-)

        • eqvet2015

          Heheh. Sorry, I didn’t see some of the other responses for some reason, and I don’t know why the formatting ended up so wonky. As veterinarians, part of our role in is to protect public health from zoonotic disease, and we are also at risk from our patients. I wish they would stick to bad Yelp reviews.

          I forgot to say that if you don’t own the animal, report it to the public health department so that they can follow up and enforce the rabies quarantine. One misconception I’ve encountered: it is NOT necessary to immediately start post-exposure prophylaxis for bites from domestic animals IF the animal is healthy and can be quarantined (or euthanized and tested). Once an infected dog or cat has started shedding rabies virus, they are going to die pretty quickly, and there is time at that point to initiate PEP because the virus takes a long time to travel up the nerves to the brain (possible exception for bites on the face).
          http://www.cdc.gov/rabies/exposure/animals/domestic.html

          • PamelaWibleMD

            Hey eqvet2015 ~ In Rob’s case cat was his own. BUT very curious how many cases of rabies have you seen in cats or dogs?

          • eqvet2015

            Personally? None. I spend more time with large animals than small animals and I am also in a region with low incidence. Nationwide, there are several hundred cats and between 50 and 100 dogs per year that are confirmed as rabid, per the CDC. Compared to other countries, rabies is much less of a burden in the U.S., probably due to the cultural unacceptability of street dogs and the prevalence of rabies vaccination.

            I suppose you could make an argument that it’s not worth the effort/time to pursue quarantine in vaccinated animals, but since human rabies is almost 100% preventable and almost 100% fatal, it would be a hard sell. Unlike many medical interventions, quarantining a domestic animal for 10 days is relatively cheap and doesn’t hurt – in many jurisdictions, owners are allowed to quarantine at home unless the animal is showing neurological signs. Brain pathology is more expensive but only needed if the animal is too aggressive or debilitated to safely or humanely house for 10 days, in which case the pretest probability for rabies goes up.

          • Geoffrey Koerner

            Thanks, eqvet2015, you wrote about cat bites in a scientifically comprehensive, yet approachable way. It kinda reminded me of Rachel Carson’s style when she wrote “Silent Spring.”

          • PamelaWibleMD

            And a humane approach always best. Quarantine at home.

  • PamelaWibleMD

    Oh thanks!! Geve is his name. He is a great guy. He is actually featured in this previous KevinMD post on racism-induced hypertension: http://www.kevinmd.com/blog/2014/01/unidentified-mans-hypertension-racism.html

  • Lisa

    My friends bill wasn’t as much as the person who went to the ER, of course not. But just washing the bite with soap and water wouldn’t have been enough.

  • Lisa

    I think my friend’s doc cleaned the bite and gave her antibiotics. No stitches.

  • Patient Kit

    My personal tendency is to avoid the ER as much as possible, even sometimes when I should go there. I once “walked” (okay, hopped) into my orthepaedist’s office on a Monday morning with a femur fracture.. Apparently, I have a fairly high tolerance for pain because I was in that condition all weekend. Not good, I know.

    I didn’t go to the ER because I figured I’d wait there for hours only to be told to see my orthopaedist, who had been treating me for sciatica, which I may have had a mild case of but it wasn’t the main problem. It turned out that I had a, thankfully benign, tumor in my femur that caused the bone to fracture. When I initially presented months earlier with pain radiating down my right thigh, my doctor ordered an MRI of my lower back but no x-ray of my femur until it actually shattered. Since I had experienced no trauma (no fall down the stairs, no car accident, etc), it never crossed my mind that my leg might be broken. I did end up needing an ambulance to take me from my doctor’s office to the hospital where I was admitted via…..the ER!

    • PamelaWibleMD

      Ummm . . . since you were seen by an orthropod why did he or she not directly admit you without having to burden the ER?

      • Patient Kit

        This was 12 years ago and I was alone and in shock while it was happening but I’m pretty sure it was the ER that I was admitted through, although maybe paperworkwise it was my private practice orthopedist who technically admitted me. I don’t know. It was the first time I was ever admitted to a hospital so I didn’t know what was going on. It was all kind of surreal.

        My doc appointment was in the morning at his private practice office.. I got there via taxi (I’m in NYC). After he diagnosed me with the fracture, his staff started making arrangements like booking an OR. He couldn’t let me “walk” back out onto the street so he called an ambulance. Our wonderful FDNY picked me up from the doctor’s office and transported me to the hospital, which was only a few blocks away. Is there a way to enter the hospital via ambulance other than the ER. I spent time there being processed and checked out pre-surgery and then had surgery around 5pm that day, which lasted for hours since it was a complex pathologic fracture. I only went up to a room after surgery. Where else could I have been for the afternoon but the ER?

      • JR

        I had a doctor send me to the ER to get a test run before – so there are some doctors who do that. Didn’t know it wasn’t normal at the time. (Let’s just say I never went back to that doctor, it was a bad experience).

  • PamelaWibleMD

    Once I had a bike wreck right outside the ER. I also had a 10K deductible on my insurance. I looked up and saw the ER on one side of the street and a Dairy Queen on the other. I just needed a bag of ice on my arm. So I made sure I could get that without a 10K bill at the ER. If not: Plan B = Dairy Queen. Since I am a local doc they gave e my own room, a bag of ice, and (thankfully) no bill.

    • NormRx

      Hi Pam, That reminds me of my own little bike accident. Yes I was stupid, so we will get that out of the way. Anyway I was riding my bike in the campground one handed because I had a Margarita in the other. I was coming down the hill quite fast and I hit a speed bump, I lost control of the bike and I and my Margarita took a dump. It was one of the worst cases of road rash I ever had. It never occurred to me to go to the ER or even a doctors office. I just cleaned the abrasions put on a bandage and I was good to go. I was about 65 at the time and I didn’t break any bones, I was either lucky or I have strong bones.

      • PamelaWibleMD

        Sound like a red neck joke:

        Q: “What does a red neck say before he dies? ”

        A: “Hey! watch this!”

        (apologizing for any offended red necks)

        • ninguem

          distant siren screams
          dumbass Verne’s been playing with
          gasoline again

          …….redneck haiku

          • NPPCP

            I resemble that remark…..

          • ninguem

            sorry Verne………

      • SarahJ89

        OMG, what a picture! I love it, especially in the middle of this polar vortex when we’re running low on wood and summer seems so very far away.

  • Anne-Marie

    Clinicians may not always realize this, but to some extent patients are at the mercy of the system.

    I know one crusty old family doc (now retired) whose response to almost every phone call re anything but the most obviously minor health concern was, “Go to the ER.” (Yes, it drove the hospital administrators crazy!) What else could the patient be expected to do? Dr. Wible is very accommodating and patient-centered but not all docs want or are able to take urgent phone calls during the day or fit patients into their busy schedule on short notice.

    Many Americans live in smaller towns and don’t have their choice of urgent care centers and Minute Clinics. Where I live, one of the larger medical clinics has an urgent care center but it’s only for their established patients, not for anyone else.. and it’s only open until 9 p.m. weekdays, a few hours on weekends, not at all on holidays and often closes early when the weather is bad. Even when patients are able to recognize their problem is not an emergency, they end up at the ER because there’s literally nowhere else to go – unless, of course, they’re OK with waiting until normal office hours.

    I also have a feeling that many people don’t really understand which level of care belongs in which setting. Knowing whether you should take your broken arm or hacking cough to the doctor’s office, urgent care or the ER may demand a familiarity with the system and a degree of medical judgment that the average person might not have.

    Not to say the ER doesn’t get misused, because we all know it does. But I’m not sure the answer is as simple as putting it all on patients to seek the appropriate level of care.

    • PamelaWibleMD

      Absolutely correct. We created this problem in many ways by not doing a better job educating our patients. And true: not everyone would wan to go in at 11:00 pm as I did last night to see a UTI that turned out to be an STD and the discuss how this sweet to-be-married couple (both present) contracted the disease. Yes, there were tears. Would not have gone as well had they been sitting in front of a doctor who they had never met in an urgent care or ER.

      • Patient Kit

        I could be wrong but I think it’s safe to say that most doctors are not willing to meet us at their office at 11pm. It’s great that you’re willing to do that for your patients, but how common is it for doctors to be willing to do that?

        • PamelaWibleMD

          Probably used to be the norm back before 1965 (pre-medicare era). Back then doctors were busy but HAPPY. With all the bureaucracy, many docs are trying to escape their workplace rather than enjoying their work. Too bad. I obviously love what I do. And I feel absolutely blessed to be able to walk into my office with a huge smile at 11:00 pm and help people.

          • Patient Kit

            Some doctors may have been happier pre-1965, but I don’t think anything in medicine (or anything else) is going to regress to the way things were back then. Romanticizing the past can be tricky be-careful-what-we-wish for territory. For starters, imperfect as Medicare and Medicaid may be, there are many poor and elderly people who are better off with those programs than without them. Also, amazing advances in medicine have created a huge population that lives long productive lives with serious chronic conditions. In the past, it was a lot cheaper when people died younger and faster from serious disease. But it wasn’t better.

          • PamelaWibleMD

            Some docs are going back to many ways of the past: house calls, direct pay models, good old-fahsioned service. Can do all of this with high-tech and modern advances. Take the best of the past and present. Neither is mutually exclusive.

          • Patient Kit

            I’m glad that you’re happy with your career and the way you practice and that you have lots of patients who benefit. The fact still remains that many people cannot afford direct pay/concierge medicine. Many elderly and poor people would be far worse off without Medicare and Medicaid.

          • PamelaWibleMD

            Direct pay models make more sense for primary care. It saves money for patients. Nobody is ever turned away for lack of money in my clinic.

          • SarahJ89

            Dr. Wible,
            I would much prefer direct pay if I could pay as I went. But the annual fees are way beyond my fixed-income budget. I am an extremely low utilizer. I show up once a year under duress to get my levoxin scrip renewed. Prior to (finally) getting correctly diagnosed I had no reason to see a doctor more than every five years or so if I had something I needed information on or couldn’t take care of myself. An annual fee simply doesn’t work for me, especially the ones I’ve seen quoted.

          • PamelaWibleMD

            Direct pay does not equal annual fee.

          • SarahJ89

            Can you explain that? I’m limited to online descriptions only since ALL of the practices in my area are owned by the local money-grubbing hospital. So what I read is a set up in which there’s a hefty annual fee, sometimes with a per-visit fee and sometimes not. I’m such a low utilizer I’d be happy to pay appropriately for my one reluctant visit a year but I simply cannot afford the $10K annual fees I keep reading about. Are there some doctors that will simply take a per visit payment? (If so, I need to move there.)

          • Patient Kit

            Again, it’s great that direct pay works well for you and your patients and that you never turn anyone away for lack of money. But I don’t see this model working for primary care in a widespread way in the US. Are you trying to convince me that primary care doctors who, in general, are saying that they can’t afford to practice on what most insurance pays them are going to take on the huge populations of the elderly, the poor, the working class — all people who can’t pay much or can’t pay at all, many of whom have serious chronic health issues? I’m not disputing whether direct pay will work well for some. I’m just saying that there are whole classes of people that it leaves out. I’m also not saying that doctors should treat people for free or little money. I think docs should be fairly compensated for the important work they do. How? Through a single payer system funded by taxes, the same way that we fund public education. I just don’t see most direct pay primary care doctors meeting their patients at the office at 11pm and never turning anyone away for lack of money.

          • PamelaWibleMD

            The haves will always be floating the have-nots. Call it what you will. I am simply removing the middlemen. My clinic is simply a microcosm of what can be done on a macro level. Primary care is not tertiary care.

          • PamelaWibleMD

            Actually, it’s rare to find a doctor practicing in any model who loves coming in at midnight to see patients. Part of the problem is we need to find our joy again. It is an honor to care for patients. The more complex and bureaucracy-laden the health care system, the less joy I experience. That does translate to less-than-optimal patient care.

            Oh, and by the way, I do not have a direct pay model. 80% of my patients have insurance and 20% don’t. So I’m direct pay for those 20%.

            If there are not enough doctors who love being doctors (and so they flee the profession) how will that help us care for the poor? As it is people who are new enrollees in our state Medicaid program can’t find docs. Oh, plus I heard we just lost 18 primary care docs from a large group in town.

            Giving people an insurance card does nothing if there is nobody with the skill, energy, or enthusiasm to care for them.

            Health insurance isn’t health care:
            http://www.idealmedicalcare.org/blog/health-insurance-isnt-health-care/

          • PamelaWibleMD

            Patient Kit ~ If you hired a third party to pay for your restaurant bill, you’d wait 2 weeks for a table, pay twice as much for your meal, and have 7 minutes to eat.

        • Geoffrey Koerner

          Good point, Patient Kit. Not every doctor is a night-owl. In my unofficial, anecdotal opinion, I think this is where an awareness of one’s doctor’s lifestyle could be applied in deciding when and who to call, e.g., “It’s Tuesday night and I know Doctor Chris coaches little-league on Wednesday after school, so if this irritating, but not urgent, cough doesn’t clear up by mid-morning Wednesday, I’ll give him a quick call for insight or to set up an appointment.”

      • NormRx

        Those damn toilet seats carry a lot of germs, SDT’s among them.

  • ninguem

    Pam, how much do you charge to interpret for the deaf?

    I’ll supply the cardboard.

    • PamelaWibleMD

      Are you tired of my cardboard-sign photos?

      • ninguem

        Just thinking it could be a new career.

        What do you call the calligraphy style?

        It reminds me of Sylvia’s cats.

        http://www.badgirlchats.com/wp-content/uploads/December-24.jpg

        • Geoffrey Koerner

          To continue the harmonic divergence, are these “cardboard signs” or “cardboard symptoms”? No need to answer. It’s just Friday and I’m in a silly mood. :-)

  • buzzkillersmith

    Dr. W., Please explain the metastatic lung CA tidibit. I’m not sure what you’re saying. Did you do a skin Bx on a pt with an unknown primary and make the first Dx?

    • PamelaWibleMD

      I described what did below in an earlier post. Excised a 1 cm nodule on posterior thorax to diagnose the primary. Yes.

  • Geoffrey Koerner

    Wow! I think stuff like this could even be taught to middle school students. If only one unnecessary ER visit is prevented, I think the “lesson” would be cost effective. Also, for those who are afraid of the ER charges and tend to “tough it out” when they shouldn’t, I think it could save their lives.

    • PamelaWibleMD

      Yes, Let’s teach real health care to middle schoolers. Great idea! In hindsight a lot of this stuff is a no-brainer. But in the midst of medical problem mixed with a dose of anxiety, it is hard to think clearly.

    • Lisa

      Make it part of a practical life skills class: How to balance a checkbook, how to budget, how to read the fine print on credit card applications and contracts, about investing. They used to teach this sort of stuff in middle school when my husband I were kids – no more. At least as far as I can tell.

  • PamelaWibleMD

    Seeing this word n the medical record always made me laugh.

  • Suzi Q 38

    That happened to me once, and I have learned.
    My cousin accidentally slammed the minivan sliding door on my thumb.
    It swelled up immediately, then broke open and there was a lot of bleeding. We panicked and i went to the ER. I was there for 8 hours.
    I finally go home hours later.
    A few days later, I went to see my PCP, who told me that I should have gone to the urgent care.
    I used to see a lot of these places around town.
    For some reason, most of them closed down.
    I would have had to stop, then look for one.
    Now I know to find out where they are now, when I don’t need them.
    That way there is a plan in place.
    Now, all I would have to do is to ask “Siri,” on my iPhone.

    Thanks for the reminder, though.

    • PamelaWibleMD

      Sure thing! Please share with others. We are needing some serious patient education here.

  • ninguem

    I’m thinking of getting a cat.

    Then I could take pictures of the cat and post them on the Internet.

    There’s just not enough of that these days.

    • PamelaWibleMD

      Good idea bro.

    • PamelaWibleMD

      Do a selfie too. So I can finally figure out who you are!!