Saturday, December 27, 2008

more proof that things really do need to change

It's not that I want people to have to pay. I sometimes feel somewhat hypocritical about charging people a hundred dollars for a doctor visit when in my heart of hearts that healthcare is an unalienable right and should be freely accessible to all. It even looks hypocritical here in print. But here's my argument: it's not just that everyone needs healthcare, its that everyone needs good healthcare. And right now, December 27, 2008, I can't deliver good healthcare for what I would be paid by insurance companies.
And another thing, I think that by continuing to work within a broken system, we are sending a mixed message. Every time I talk to family docs we talk about the unfair payment of insurance companies. Again, I reiterate, we are the ones agreeing to take the crappy pay!!!!! But we are also sending a message to our patients. We want our patients to be educated and empowered and proactive about their health, but then we all to often allow them to think that insurance company rules are more important than our recommendations. Three months ago a woman in her 50s was in my office for a check up, her mammogram was (my favorite) "probably benign" asymmetric density, (irregular lump) recommend 6 month recheck. Knowing her family history, and the fact that she had abnormal mammograms before, I decided that neither she nor I was comfortable with waiting to check out an abnormal, even if it is "probably" benign, so I recommended a breast MRI, something, I realize, that I probably wouldn't have been able to do in a land of "nationalized healthcare". Turns out I can't do it here either. Despite two appeals, it was denied by her insurance. So I explained to her that a lump is a lump, and she should see a surgeon to see if it should be biopsied. The surgeon agreed with me, and ordered an MRI, but never told me the outcome. Three months later she came to my office for "follow up" and I said, "I never heard from the surgeon, what were the results?" and to my shock and dismay she told me the insurance also denied the MRI request from the surgeon so she never followed up (and neither did the surgeon). I told her she must go for mammogram and ultrasound to evaluate for change now. She told me she was afraid the insurance company would deny that, too, since the radiologist recommended 6 month. It got approved, and unfortunately, the irregular lump is now bigger. Lots of things should have been done differently. I don't know how this will turn out, and I pray for a negative biopsy for her.
The fact is, our system was set up to make her feel like the insurance company had the last word, and we have let this happen. And we must stop. I realize that this is not directly related to my practice style, but indirectly it is. Because every day, when my patients make the choice to come "out of network", they are reminding themselves (and me) that good care trumps insurance policy.

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