The Doctor will see You... For $3500

My grandmother went to the doctor this week with a sore on her leg. She came home with a bill for $3500. The bill had nothing to do with the treatment of her leg wound. The bill was to cover the doctor’s new annual membership fee. If she does not pay it she will be forced to seek care elsewhere. She is 95 years old and on a fixed income and will need to either pay up or move on.

Her doctor left me a lengthy voice mail explaining his fee, informing me that it will allow him to spend more time with each patient and provide high quality care. What it won’t do is cover any of her visits for the year. Those are extra and will be billed to her insurance. The $3500 is for access alone.

The fee seems exorbitant and it is. A typical senior citizen goes to the doctor 6 times a year. The fee works out to a payment of an additional $600 per visit, an astronomical sum.

While the charges are insanely high they are becoming increasingly common. Doctors who cannot make ends meet on what insurance companies pay are looking to their patients to pick up the slack. Especially for older and sicker patients, insurances don’t pay enough to cover the time needed, typically only about $120 for a 30 minute visit. This may seem like a lot, but after factoring in overhead ($160 an hour) and unpaid time spend on refills, phone calls and emails, the end result for the doctor paid this fees could be a salary of about $120,000 a year. While this is a good wage for many people it isn’t enough for a doctor with student loan debt to live in Southern California, where mortgages for a modest home can exceed $4000 a month. Many doctors are desperate to find a way to increase their income.

While this is understandable, the $3500 fee seems excessive. It seems that a doctor with 2000 patients in his practice could make ends meet by charging much less. $100 a year would result in a $200,000 a year increase in salary and make up for what insurance pays. Why charge $3500.

My recent experience answers the question. The majority of patients won’t pay the smaller amount either. My office provides a wide array of services, from guaranteed same day access and short wait times to digital visits and email communications, that are not covered by insurance plans. To cover the cost of these services, on January 1 of this year we started charging an annual access fee of $120. While we thought this was reasonable and affordable we have lost over half of the 1000 patients to whom we billed the fee. In their minds the additional access and services just aren’t worth it. It is apparently easier to find 200 patients willing and able to pay $3500 a year than it is to find 1000 patients willing and able to pay $120. My grandmother’s physician has figured this out.

This does not bode well for the future of medicine. None of the current health care plans being discussed in Washington D.C. or Sacramento address the reality that good medical care costs a lot of money and that quality doctors require competitive salaries. Patients unwilling or unable to pay extra for services will find it increasingly difficult to find a primary care doctor willing to see them and will be increasingly unhappy with the options available. It seems we are headed for a crisis of inaccessibility.

The solutions to this problem are too complex for a blog post but there is one thing of which I am certain. These solutions will not be easy and will be expensive.

-          Bart

Drug Secrets Your Doctor May Not Know

The patient was angry. His pain management doctor had written a prescription for a new pain medication and the patient expected it to be covered by his insurance. It wasn't, and the patient was stunned by the drugs $320 price tag. There was no way he could afford the drug and he went home empty handed and in pain. 

Stories such as this are not at all uncommon. Prescription coverage varies widely from one insurance to the next and seems to change daily. It is impossible to keep current. Previously covered and once inexpensive generic medications become uncovered and expensive seemingly overnight.

A week ago I wrote a prescription for doxycycline, a 48 year-old antibiotic that  a few years ago had a cash price of $4 at Target and Wal-Mart.  Imagine my surprise when the pharmacy called saying it was not covered by insurance and the cash price was now $65! How does that happen?

A few months ago a patient called asking for help with his sleep medication. His insurance would not cover generic Ambien and he could not afford the $85 his pharmacy charged for 30 pills. I had my staff check on what our cost would be if we ordered it ourselves. Our price- 100 pills for $3.10. The pharmacy was charging $85 for a medication that cost them $1!

100 mg Viagra tablets cost almost $30. Five 20 milligram tablets of the same drug from the same manufacturer, sold under the brand name Revatio, can be purchased for $4. When I asked the drug company salesman why this was he could not provide me with an answer.

There are many aspects of medical practice that are frustrating but medication costs and coverage are of particular concern. New drugs are always ridiculously expensive, with thirty day supplies of new medications consistently above $150. The prices are often concealed from doctors by sales people whose presentations focus on co-payments and discount cards instead of total costs. 

What can patients do to navigate such a system? I am often confused and perplexed by insurance coverage of medications, how can a lay person be expected to know what to do? We are in desperate need of greater transparency in how medications are priced.

While we wait for that day to come here are a few recommendations-

1- Tell your doctor when a medication is expensive. There may be less expensive alternatives. My daughter was once prescribed a medication that cost $700 a month. The doctor was shocked to learn of the cost and changed to a more affordable option.

2- Shop around. Prices can vary widely from pharmacy to pharmacy. A few years ago I called several pharmacies to check their price for generic Prozac. The four prices were, $7, $11, $25 and $40 for a one month supply. Do not feel as if you do not have choices.

3- Ask for an inexpensive drug. For common conditions such as high blood pressure, diabetes and sinus infections there are usually very inexpensive options. Target and Wal-Mart sell a 30 day supply of many common generics for $4.

4- Use coupons. Web sites such as goodrx.com can offer sizable savings. Almost every brand name medication will have coupons on their websites.

5- Fight when needed. I recently had a patient who was taking a medication twice a day for chronic pain. It worked well but wore off in the middle of the day. I gave him a sample and suggested he try taking the medication three times a day. He was thrilled to report dramatic improvement so I sent the new instructions to the pharmacy. His insurance denied the claim saying they would only cover the medication twice a day. I wrote two letters and personally called the insurance but they did not budge. He appealed the denial all the way up to the California Board of Managed Care. The Board notified him yesterday that his insurance would be required to pay for the medication. It took more effort than it should have, but he won!

- Bart

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Medicine is Changing. Are you Ready?

Medicine has changed and many patients did not get the memo. Electronic record keeping and computerized data bases have made it so every aspect of a patient's health is now monitored, tracked, and analyzed. There is no longer such a thing as a simple office visit as third parties are telling doctors what to do, how to do it and who to do it to. 

When I started in practice 21 years ago the business was pretty easy. Most patient visits could be divided into three categories- routine check-ups, follow up for chronic diseases, and sick visits. Check-ups were straight-forward, uneventful reviews of overall health. Chronic disease visits were also easy, encounters focused on the problem in question- check the blood pressure, review the cholesterol or blood sugar, and make medication adjustments and order appropriate tests. Sick visits were easiest of all, as most of them were upper respiratory illnesses that could be handled quickly. 

Another characteristic of that era was that patients were responsible for their own care. We told them what they needed to do to be healthy, recommended screening tests such as colonoscopy and mammograms and encouraged appropriate diet and follow up tests. Whether or not they wanted to follow instructions was up to the patients. Being human beings, many patients didn't. Some forgot, many simply had other priorities. It was frustrating when patients did not do what they should for their health but we accepted the reality of the situation.

There was another reality that eluded both doctors and patients, and this reality led to changes in the way health care is delivered. The bad decisions patients made did not just effect them. When illness occurred as a result of these poor choices someone else, the insurance company, had to pay the bills. Insurers decided they wanted healthier patients and determined that reaching this goal required a dramatic change in how doctors practiced. The change came in the form of quality measurements. Doctors were to be held accountable for the decisions patients made, graded and financially incentivized based on the percentage of their patients who did what they were supposed to.

A new era of accountability has dawned. Doctors are now bombarded with forms and scorecards showing the percentage of patients who had mammograms, Pap Smears and colonoscopy. Reports pour in every week with the names of patients who have not been filling prescriptions on time, asking doctors to confront their patients about their non-compliance. Hours and hours of staff time are spent tracking chronic disease such as diabetes, with patients being reminded again and again to get eye exams, control their blood pressure and cholesterol and get their sugars under control.

The rules haven’t only changed for disease management. MediCare wellness guidelines are so arbitrary that we are required to annually discuss incontinence, fall risk, memory loss, ability to care for oneself, end of life issues and control of chronic pain with every single patient above the age of 65 regardless of health status. We have to check the same boxes for a debilitated 88 year-old as we do for a vibrant 65 year-old who plays competitive tennis, which is a bit puzzling to the 65 year-old!

The result of all of these metrics, reports and guidelines is that patients who come in for one problem find themselves being bombarded with instructions and questions for multiple other conditions they didn’t come in for. This can lead to defensiveness and a breakdown in communication, encounters that leave both the patient and the doctor feeling frustrated or dissatisfied.

So what to do? We start by understanding the new paradigm. I have begun educating my patients about the changes in healthcare. I explain to them the standards to which I am held and how their compliance has a dramatic impact on my practice and I am asking them for their help. The result? Increased cooperation, better understanding and decreased frustration. Medicine has changed  but if doctors and patients truly partner together we should be able to find a way to make it work for all of us.

- Bart

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