In late 2019 I began to write about my experiences as a Family Medicine Physician, and particularly my motivations, reasoning, and practice style. Over the last decade of medical school, residency, and practice, I had come to believe that the steadily eroding trust in doctors was a true public health emergency. My theory was that, while some of this was due to profit or power-driven elements like the anti-vaccine movement and alternative health industry, and some was due to legitimately unconscionable treatment at the hands of a relative few unethical and immoral doctors, the vast majority was due to the complex and often confusing nature of medicine itself. I believed, or at least hoped, that if people understood their doctors better and knew how deeply they cared about their patients and how hard they worked for them behind the scenes, they would come to see doctors- and other healthcare professionals- as I do; as their allies and advocates in our deeply broken healthcare system.
Since the COVID-19 pandemic began I have found my attention called more and more to medical misinformation about the virus, which is what ultimately led to my starting this blog. Yet at the heart of so much of this misinformation is that same mistrust and suspicion. So partly to find a home for these few stray essays, and partly to continue pursuing my original goal of pulling back the curtain and helping others better understand the convictions and reasoning their doctors bring to their care, I am sharing these posts here.
Originally posted December 5th, 2019.
30 Days on Doctoring: I absolutely do look at your insurance.
Every day I hear from a friend or a patient, or see an article, a post on social media, or somewhere else where someone has written that your doctor only cares about you if you have the right insurance. Doctors will only order the right test, only give you the ‘real’ medicine, only spend their fair share of time face to face with you if you’ve got the right coverage. The link between your local PCP and the Walgreens across town or the medical equipment company isn’t exactly clear; somehow the doctor is getting kickbacks, though, and those kickbacks don’t happen if you are paying out of pocket or if you have to use a coupon or have the types of insurance that don’t come with a premium ‘gold status’ membership; to have the right insurance is to be in the club, and everybody else is left to suffer and make their way the best they can.
I’d love to tell you that I don’t care what insurance you have. I’d love to say it just doesn’t matter to me, that every patient gets an equal share of my time, energy, and attention. I’d love to tell you that I treat your CHF and shoulder pain exactly the same if you have Medicare, or Blue Cross and Blue Shield, or our local state grant funded coverage program, or are paying out of your own pocket.
But it isn’t true.
My confession: I absolutely look at your insurance. Every day, every patient, every visit. I may even ask you what insurance you have, right in the middle of our visit, just in case that tab on my computer screen isn’t accurate or up to date. Let me tell you why.
Let’s say you come to me for that congestive heart failure that we just mentioned. For the sake of discussion, let’s say you’ve never been diagnosed with it before and have only recently developed the symptoms (dyspnea on exertion, unexplained weight gain, swelling in the legs) and have risk factors (a heart attack a few years ago, years of high blood pressure, a strong family history of heart failure). I’m going to need to do a few things regardless of who you are and what your insurance is like. We are going to spend time talking about your symptoms; when did they start, what have you tried already to relieve them, are they getting worse and if so how quickly? We are going to talk about your history; has this happened before, has it already been worked-up and to what extent, any other medical problems that could be causing these same symptoms, mimicking CHF? And we are going to do an exam; listen to your heart, listen to your lungs, press on your legs to see if and how much swelling you have and whether it is pitting or non-pitting, check your abdomen for pain and free fluid or enlargement around the liver and any signs of cirrhosis (which causes a lot of the same symptoms as heart failure). We are going to do all of this for every single patient presenting for the symptoms of CHF. And then we are going to get an EKG, because it’s quick and fairly cheap and can be done in my office and gives us some good information about your heart.
Then I’m going to look at what insurance you have- and maybe even ask a little bit about your finances- because here’s what else we need in order to figure this out:
- Basic labs including a complete metabolic panel (CMP- information about kidneys, electrolytes, and your liver), maybe a complete blood count (CBC).
- A B-natriuretic peptide level. This is a protein produced by the chambers of your heart in response to increased stretch/pressure, and it helps lower pressure and -as the names suggests- works as a diuretic to clear fluid. As a lab test, we use it as a surrogate for how much the pressure within your heart chambers is increased; a marker of congestive heart failure and the resulting overload of fluid.
- A Chest X-Ray to evaluate whether there is extra fluid both in the blood vessels that supply your lungs and in the pleural space around your lungs, and whether your heart is enlarged.
- An Echocardiogram; this is an ultrasound of your heart and the most important test in your CHF work-up; it tells whether the heart is actually pumping normally and if not, exactly which chambers, valves, and phases of your heart beat are affected.
- A referral to a Cardiologist, and probably some associated programs like CHF clinic and cardiac rehab.
- Treatment! Not only cardiac rehab, but dietary and lifestyle changes and also multiple cardiac medications.
- A follow-up appointment with me to look at the results of all of these tests, make sure we really have the right diagnosis, and evaluate whether your treatment is helping you at all.
You’ve all been around the block, so I don’t have to tell you how expensive this is all going to be. The answer is: probably very very expensive.
And if you have Blue Cross Blue Shield, or better yet Medicare or Medicaid, that’s probably ok. You’ll have some out of pocket expense and maybe have to meet a deductible; it could still be a financial hardship, but with your insurance it shouldn’t be a true financial disaster, at least not all at once.
But what if you don’t have insurance? Or what if your coverage is grant funded and only applies to the treatments we can do in-house? Well now we have some decision to make.
Labs: Some of this blood work is more expensive than others, and some is more vital for working-up this condition than others. In some situations our in-house lab is going to be your cheapest option, but sometimes it’s going to save you a lot of money for me to order the labs to be done at another site where you pay cash up-front for a cheaper price. This is actually more work for me and my staff, but if it saves you the money you need to put away to get some of this other work-up done (or, you know, pay your rent this month), then it’s worth it. The decision of where to do which labs and trying to figure out how much it’s going to cost you is one I have to make a dozen times a day.
Imaging: Again, we can do some of this in-house, but we’ll need to talk about the cost. I don’t have as many options for outside imaging; we can do your x-rays here and the hospital can do your Echo, but there are costs associated with both. If you are paying out of pocket or only some of these tests are going to be covered, we need to prioritize and work on figuring out exactly how much each is going to cost you. Some hospitals have patient assistance programs; maybe you would qualify, so we need to get you in contact with the right department and start getting cost estimates. Again, more work for me and my staff, not to mention for you, but the alternative is for you to end up with an unexpected $2,000 bill for the Echo I ordered, and then you might not be able to afford the ACE Inhibitors, Beta Blockers, and diuretics you are going to need to actually treat this condition. Which brings us to…
Medications: Do you know how much a month’s or 3 months’ supply of those medications costs? Do you know which is cheaper with HEB or Wal-Mart generic pricing, which is cheaper with a GoodRx coupon (at the pharmacies that will accept one), and which is cheaper at our clinic’s pharmacy? I do, because a medication left at the pharmacy because it was too expensive has just unbelievably poor bioavailability. It looks great on paper if I prescribe all the right, best medications; it does nothing to help your heart if you can’t actually get those medications. So we are going to talk about each medicine and the rationale for it, the risks and benefits, etc.; of course we are. But we are also going to talk about which pharmacy you want to use, how much I expect it to cost there, what the alternative options are, and because I’ve been burned in the past I’m going to say the same phrase at the end of almost every single patient visit; “If you get to the pharmacy and one of these medications costs more than we are expecting, and the cost is prohibitive or just seems really high, please call us before you buy it so we can look for a coupon or recommend an alternative.” The first time your patient tells you they borrowed money from friends and family so they could pay for the $120 medication you prescribed, when you know it was actually $8 at another pharmacy or with the right coupon, you will start saying this at the end of every visit too.
Specialists: We have a lot of excellent specialists in the city where I work, and ideally your CHF is going to be managed through regular visits with a Cardiologist and CHF clinic, with me along for the ride to explain things when they aren’t clear, keep an eye on your other medical issues, and keep you out of the hospital (or get you to the hospital) when you have an exacerbation and your Cardiologist is booked solid or not available in clinic. If you have private insurance or medicare, that will almost definitely happen. Even if you don’t have great insurance coverage, this is still ideal, and I have many patients who have worked with the local specialists to come up with a payment plan; I don’t know the details of those arrangements, but I’m often pleasantly surprised by how much our specialist clinics work with people to get them seen. If that’s not possible, many of the specialists in town create access for our patients by volunteering their time at our clinic. Often times there is a wait list, though, and until then (and in between visits), I get to be your “cardiologist”. Or your “rheumatologist,” “pulmonologist,” “endocrinologist,” or you name it. I put those in quotes because while as a full-spectrum Family Medicine trained Physician I have worked and trained and studied in all of those areas of medicine, I am an expert in none; ours is a Jack-of-All-Trades specialty by design. But if your financial and insurance coverage situation means that you can only see me right now, you can believe our visits are going to be longer and more frequent.
Follow-Up Appointments: I can’t count the number of times that I’ve asked a patient what their co-pay to come see me is, only for them to start explaining when they are going to pay their bill or some similar concern, as though I knew what their account balance was and wanted to make them feel bad about it. I’m grateful to work in a clinic where that is not my job at all. I’m asking because if your Co-Pay is $10, I’m going to be prioritizing some of the above conversation for today and save some of it for 2 weeks from now, so you don’t feel overwhelmed and have time and space to process your diagnosis. If your co-pay is $80, or you have no insurance and so you are footing the entire bill, we are going to address as much as humanly possible because I know seeing me again in 2 weeks is going to be a burden, and if there’s a way we can put it off for a month by doing more today, then we will.
So the TL;DR version here is that I definitely do look at your insurance. Because if you have great access to wraparound care, testing, and specialists then you aren’t any less deserving of my time, but you probably don’t need quite as much of it, at least usually. But if you have limited access, you aren’t any more or less deserving of my time or energy but you are probably going to need more of both; if you only have a few medical professionals in your corner, then each of us is going to have to step up and give some more time, some more creative thinking, and some more effort to get you the closest thing we can to comparable, just care. The only alternative is to simply accept health disparities as an unavoidable and uncorrectable fact of life, and that’s something our Oath just doesn’t allow for, no matter how broken the medical industry we work within happens to be.