Tag Archives: insurance company

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from blue to breathe

I attended a medical conference on line yesterday and today and it made me very blue. At first it just frustrated me, because it is about increasing behavioral health access. Isn’t that a good thing? Yes, but they completely missed the biggest barrier for primary care: TIME.

With the current US medical corporate money extracting insurance non-caring system, primary care is increasingly forced into 20 or 15 or 10 minute visits. I fought my hospital district when they said “See patients for one thing only.” I replied “That is unethical and dangerous: if it is a diabetic with an infected toe, I HAVE to check their kidney function, because antibiotic dose must be adjusted if their kidney function is reduced.” And there are at least two and maybe three problems there: infection, and if the diabetes is out of control that worsens the infection, and then kidney function. And actually I have to be sure anyone going on antibiotics has good kidney function or adjust my dose. I am very very good at this, but it takes time. I can work with complex patients, with veterans, with opiate overuse, with depression: but none of this is a simple template slam dunk. A study more than a decade ago says that the “average” primary care patient had 5 chronic illnesses. My patients don’t want to come in for each one separately and anyhow, if they have kidney problems I have to pay attention when I pick medicines for their high blood pressure. None of it can be separated out. That is why medicine is complicated.

Someone asked why can’t I just post the price of a “simple” visit for a sore throat. But a sore throat can be viral, can be strep A, can be a paralyzed vocal cord, can be a throat abscess, can be vocal cord cancer. I can’t tell ahead of time. I can’t. Early on during covid, a patient called and wanted a Zoom visit for abdominal pain that he said was constipation. I said “No, I can’t do abdominal pain over Zoom safely.” I can’t ASSUME it is constipation. It was appendicitis and he had his appendix out that evening. He called from his hospital bed the next day to thank me for making him come in.

The conference made me blue because they ignored my questions about why they were not advocating for primary care to have more time with patients. They claim to be all about change, but changing the US medical system? Nope. Do not want to talk about that. But I do want to talk about it. You can help by letting Congress know: single payer or medicare for all. That insurance company gets 20 cents of every dollar to profit and wastes tons of money forcing doctors’ offices to call for prior authorization. And if we have single payer, think of all the small businesses that will start because the terror about health insurance will disappear! I think it would reduce everyone’s stress, except the insurance CEOs. And they have earned more than enough, goodbye greed.

I am also tired of specialists telling me that primary care needs to do MORE. When I get told that I am not doing enough about hypertension, bladder leakage, depression and stopping smoking, and then 20 other specialists lecture me. Ok, so one minute per topic to fulfill what all of them think I should do? I want a primary care conference where primary care doctors are celebrated: cases are presented where the specialist says what a brilliant job the primary care doctor did.

I received a consult letter from a cancer doctor a few years ago. He wrote that I had diagnosed the earliest case of chronic leukemia that he had ever seen and that he was impressed and the patient would do fine. That’s the conference that I want to go to: where primary care and specialists talk about that and we inspire more doctors to do primary care.

You can learn more and how to talk to your congressperson here: HealthCare Now: https://www.healthcare-now.org/

or at Physicians for a National Healthcare Program: https://pnhp.org

And put your vote and your money towards healthcare, not health insurance.

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Fraud in medicine: why “help” won’t help

This article:  Doctors wasting over two thirds of their time doing paperwork showed up on Facebook yesterday.

The problem is that “hiring people to help with paperwork” will not help.

Why? We’ve already done that and it’s a huge mess.

For example: I was referred to an Ear Nose and Throat Specialist at one of the Seattle Mecca hospitals. I had to travel two hours and then in the waiting room I was given a four page patient history to fill out. I filled it out. I had been referred by a Neurologist, who sent a letter and note. After I filled out the forms, HIPAA and “you will pay if your stupid insurance won’t” and address and consent to be treated and yada yada…. I waited.

At last I was shown to a very luxurious room. There a medical assistant asked me many of the same questions that I’d filled out on the form and which were already in the letter and note from the neurologist. She typed these into the EMR- electronic medical record. Then she left. And I waited.

At last the distinguished otolaryngologist entered the room. He said, “I see that you are here for chronic sinus infections.”

“No.” I said. “I am not.”

Silence.

“I see that you did not read anything I filled out and I am a physician and I drove two hours to see you.”

Silence. “Um.” he said. “Uh, why are you here?”

“Strep A sepsis twice and we want to know if my tonsils should be removed.”

Right. So… all that paper you fill out before the physician saw you? Yeah, like, my impression is that physicians don’t read it until after you leave. And maybe mostly don’t EVER read it.

I plan to find out the next time I have to see a specialist. I will write “you don’t read this anyhow, so I am not filling this shit out” on page 2 and see if the specialist notices. Bet you money they don’t. Though when they yell at their staff for not entering my medication allergies or the review of systems, they might notice.

So… I am a primary care physician. What do I do?

A new patient has one form: name, address, insurance information, hipaa and “you pay if your insurance doesn’t”.

I do the health history myself in the room entering it in the first visit, which takes 45 minutes to an hour. WHOA! INEFFICIENT! Nope. Actually it is brutally efficient. For four reasons:

One — I enter it myself and ask the questions myself and I am really fast at it.

Two — now I know the person, because I went over all of it: complaint, history of present illness, past medical history, social history, allergies, review of systems, and I ask people to bring all their pills including supplements to the first visit and I enter them too. And I look at the bottles. I don’t like vitamins with 6667% of the Recommended Dietary Allowance of any vitamin, lots of vitamins now have herbs in them too and I would not recommend taking cow thymus, labeled as bovine thymus.

Three — Now I don’t have to spend time reading forms filled out in the waiting room or a history entered by someone else, because I don’t have time to do that anyhow. I did it all in the visit. I will still have to read old records and any labs or xray results or consult notes or pathology reports and hey, where do you think the waiting room paperwork falls in that priority list? Yeah, like never.

Four — I hand people a copy of the note as they leave and ask them to read it and to bring corrections if I got it wrong. They go from thinking that I am a drone staring at the laptop to saying, “Hey, she typed nearly everything I said (and she has three spelling errors).”

Because the truth is that medicine is really complicated now and it just doesn’t help to have more people “do the paperwork”. I have to read the notes and labs and reports myself, because I am the physician.

There are three things that WOULD help:

1. One set of rules. Hello, the insurance companies, all 500ish of them send us postcards and emails every week saying “Hey, we’ve changed what we cover, meaning we cover less and we have new improved and more complicated prior authorization rules! Go to our website to read all about it.” Guess how often I have time to do that. NEVER NEVER NEVER. I read medicare’s rules. So medicare for all, single payer is partly to have ONE SET OF RULES. I can memorize miles of rules, but not if they are changing in 500 companies every week. Shell game. Also, prior authorization means “your insurance company is making your doctor fill out paperwork in hopes that they can delay or refuse the care your doctor thinks is best for you.”

2. One electronic medical record. Right now there are about 500 of them too and none of them talk to each other so we are all “paperless”. Ha. It’s worse than ever, because we get 100 pages or 200 or 300 of printed out electronic medical record for every single new patient. I need two more big file cabinets for my “paperless” office. Hong Kong did it in 9 months. What, are we wimps? Make a decision.

3. Standardization of lab and xray and home health and physical therapy and nursing home and rehab and hospital order forms. Because every stupid lab form is different: not only arranged differently but also the lab panels are different, the requirements for what that lab wants to fill the order is different and the results are arranged differently on the page. Hello. Stupid, right? Any efficiency expert would laugh.

And that’s how we could really help doctors help patients.