Does the patient come last in health care?

In the service industry — which as physicians, we certainly are a part of — a popular saying is that the customer always comes first.

The implication is that in order to thrive in an industry, you have to cater to the customers/patients as it is they who will ultimately decide where they take their business.

In medical school, the emphasis on prioritizing the patient was evident, culminating in the Hippocratic Oath that every graduating medical student recites prior to assuming the mantle of a physician in society.

Sadly, phrases like “the patient comes first” are now relegated to just lip service in modern medical times.

Say it isn’t so!

How can the noble profession of medicine whose entire mission is saving and improving patients’ lives not put patients first?

It is hard to pinpoint when this physician-patient model got warped in its implementation, but I would venture a guess that it occurred shortly after priorities shifted from the patient to the financial bottom line.

I can’t speak for every specialty, but I can certainly shed some light on what is going on in radiology in the current medical climate (spoiler alert: patient care is a low priority).

I do understand the business model of insurance companies and know where they are coming from.

Medical insurance companies charge premiums for their customers and hope that this amount exceeds the medical services they have to end up paying so that they can indeed pocket the profit.

It might be surprising, coming from a radiologist whose livelihood can depend on imaging being ordered, but I am not against them trying to curb the expenditures on advanced modalities such as CT and MRI — which are the priciest equipment to play with.

The pioneers of medicine, such as the renowned Sir William Osler, practiced great medicine well before the first patient was ever put in an MRI or CT and relied on clinical skills to come up with remarkable diagnoses.

One famous example of such is when Osler correctly diagnosed a patient as having aortic insufficiency just by feeling the patient’s toe (the “water-hammer” pulse sign).

It does not have to be a knee-jerk reaction that, for every presenting symptom, you have to order a CT. However, in “cover your ass medicine,” this is quite difficult not to do as the fear of litigation for missing something weighs on every practicing physician’s mind.

There are some insurance protocols, however, that I do find quite objectionable and clearly demonstrate how they regard both physicians and patients alike.

At some time or another, we have been patients in the medical system.

It is often an inconvenience to go to the doctor’s office to get a check-up or problem looked at.

Our schedules are busy, physicians, or not, and this may involve taking time off for work as well as traveling to the facility.

It is therefore quite reasonable to wish that every study/test ordered could be done in one visit for convenience’s sake.

However, patient satisfaction/convenience apparently has no bearing with some standard insurance protocols in place.

I am sure there are countless examples, but I will list a few to drive home the point.

Some “genius” honcho in the medical insurance industry decided that even if they are completely different studies, if the area of concern overlaps in the human anatomy, only one study can be performed and reimbursed for a particular patient visit.

Your patient has thyroid nodules that need imaging evaluation, and you are worried about atherosclerotic disease in the carotid arteries?

You appropriately order a thyroid ultrasound and a carotid ultrasound.

Your patient is out of luck, however, because the ultrasound probe has to be put in the same anatomic region (neck), and thus the insurance company will only pay for one study if both are done on the same day.

To avoid this, the patient ends up having to come on a separate day to have the additional study performed.

It makes the radiology department look like the bad guys as patients are often forced to travel over 30 miles each time (and some even further).
The exact same scenario plays out if you are worried about a patient having a deep vein thrombosis/clot, venous study, and atherosclerotic disease (arterial study).

Each of these studies is ultrasound technologist labor-intensive and looks at different structures despite being in close proximity to each other (leg).

But this argument falls on deaf ears when trying to explain it to the insurance companies who will not allow both to be performed on the same date.

Again highly inconvenient and further proof that the patient comes last.

Unfortunately, insurance reimbursement policies also affect the physician.

It is logical to assume that if something takes longer and requires more detailed work/analysis, then it should be reimbursed higher. Alas, this is not the case in the eyes of the insurance company, who often defy logic.

Take MRIs: A routine head MRI can take around 30 minutes to scan.

If a clinician wants a more detailed analysis of a particular structure, say the trigeminal nerves, we add more imaging sequences that can almost double the time.

This more detailed study also generates significantly more images for the radiologist to view.

You would, therefore, think this study would receive a higher reimbursement to compensate for the extra magnet and physician time.

You would be wrong.

Thanks to how medical coding has devolved, both studies are now coded, and thus reimbursed, the same.

It is akin to having a landscape company just mow your lawn one day for the basic price and the next time do the same service but in addition, require them to trim every tree, bush, do edging, etc. and then say you will not pay them a penny more.

It wouldn’t fly in that industry yet we are forced to accept it in ours.

It would certainly be nice to go back to the days when the doctor-patient relationship actually meant something.

However, with the insurance companies/bureaucracies interloping as middle-men, that period of medicine appears to be from a bygone era.

Xrayvsn” is a radiologist and can be reached at his self-titled site, XRAYVSN.

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