I just read an article about expectations in medicine.  Expectations can make or break a relationship.  They can be the source of great excitement and joy or of great disappointment and sadness.  Expectations, in medicine need to be clearly defined and, when possible, successfully met.

Several years ago, I did a full physical on a new patient.  Patient “X” had been referred to me by a mutual friend and I did my usual, thorough job.  I was dismayed when my friend called me to report how disappointed patient “X” had been!

I called patient “X” to discuss the results of his exam and why he felt I did a “crappy” job.  Mr. “X” started with, “Doc, I like you, but you did not do/order a stress test, Carotid Doppler, lung function test, PSA or colonoscopy.  I went to Dr. “Y” and he ordered them for me!”  To Mr. “X’s” surprise, I asked him why he thought he needed those tests.  Mr. “X” responded, “My partners’ docs ordered those tests.”

In retrospect, the problem was obvious.  Mr. “X” had expectations I did not meet.  I had expectations, as well.  My expectation was that Mr. “X” wanted a thorough, customized physical.  “Mr. “X”, I’m sorry you were unhappy.  Let me venture a guess:  your partners are all in their mid-sixties.”  His answer was “yes”.  “Mr. “X”, had you been in your sixties, I would have ordered those tests and perhaps more.  You are 41 years old and, with your personal and family history, as well as excellent physical condition, I did not feel you warranted any of those tests.”

Mr. “X” cancelled all of his tests and sees me yearly for his exam.  I learned a valuable lesson.  My patients’ expectations may not match mine.  Setting realistic expectations are an important part of any doctor-patient relationship.  Patients must recognize that doctors have expectations and doctors must realize that patients have their own, distinct expectations.

Expectations can range from fantasy to reality.  In the medical arena, it is crucial that expectations be founded in reality.  As your doc, I expect you to follow my instructions.  I expect that, if you are going to vary from my instructions, you will let me know.  These are realistic expectations.  

An example of false or unrealistic expectations would be if you were 75 pounds overweight, drank a bottle of wine and six cocktails, and smoked two packs a day; and I expected you to lose your excess weight while giving up smoking and alcohol simultaneously within 6 months.  (I would give the above patient at least 6 1/2 months). 

Sometimes I set unrealistic expectations for myself and my patients.  When the stakes are high enough, you do what you have to do in order to survive.  Unrealistic expectations can be met when truly necessary!

Patients often set unrealistic expectations.  The most common example of an unrealistic expectation is when the patient, mentioned above, expects his doc to cure his cough, repair his damaged liver, and save him from the heart attack he is about to have.  Doctors don’t heal patients; they help patients heal themselves.  Expecting your doc to save you from a sinking ship while you are punching holes in the hull is another example of false expectations.

So, what can you do?  Discuss your expectations with your doc.  Let him/her know exactly what you want; what you are thinking.  Be sure of what your doc expects of you.  Expect that your doc will work your expectations.  If he/she falls short, discuss it with him.  Work at meeting your doc’s expectation.  Expect that your doc will confront your shortcomings, as well.  Most of all, be honest with yourself and your doctor.

P.S. – I believe in miracles.  I have been blessed to see many miracles in the last 40 years of practice.  It is ok to have false or “fantasy” expectations, as long as you know that the only way they will come true is to receive a miracle.  It is not OK to sell yourself on false hope as the vast majority of time it will end in disaster.  

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Medically speaking, what’s a guy to do when there is no right answer?  My patient’s solution is often to ask me what I would do given his particular circumstance.  He isn’t happy when I respond with, “I truthfully don’t know!”

In reality, I always know what I would do.  I’d gather knowledge, see consultants, and explore every possible option to its fullest.  Then, most probably, I would still not be sure what I would do unless I was in the situation myself.  “What’s a man to do” is a very personal question with many, nonscientific factors to be taken into account.

Case in point.  I’ve counseled many patients with prostate cancer.  I know all the treatments available and the pluses and minuses of each approach.  The common options include “watchful waiting”, some form of radiation, surgery, or a combination of the latter two.   

What’s a guy to do if he has prostate cancer?  This is one disease where the answer is difficult and the stakes high.  Several years ago, I had an elevated PSA (screening test for prostate cancer) and an abnormal prostate exam.  While waiting for my biopsy results, I got a chance to look at all the options from a patient’s point of view.  I now know what I would do if my biopsy was positive, but my decision-making process was unique to my life and what I feel is important.

I counseled a patient with a precancerous lesion of his colon.  A routine screening colonoscopy revealed a polyp (tubular adenoma) that could not be fully removed by the gastroenterologist and has the potential to become a cancer.  Again, his options were watchful waiting with careful follow-up versus a surgical resection of part of his colon.

What’s a man to do?  Watchful waiting means yearly colonoscopies and biopsies.  In my early days as a doc, I saw a young lady with a slightly abnormal mole on her back.  I started to advise a watchful waiting approach when I realized that I was watching to see if she might develop a malignancy.  After I explained my reasoning, I removed the lesion.  The pathology report came back as an early stage of melanoma, a particularly nasty cancer.  Since then, I have not been a fan of watchful waiting.  Luckily for my patients, I surrounded myself with conservative surgeons who provide a nice balance to my aggressive surgical leanings.

Colon resection is no picnic, either.  To have a colon resection for a lesion that may never turn cancerous carries its own risks and expense.  What’s a guy to do?

In the business world, it’s called “due diligence”.  According to BussinessDictionary.com, due diligence is a “measure of prudenceresponsibility, and diligence that is expected from, and ordinarily exercised by, a reasonable and prudent person under the circumstances.”  A reasonable and prudent patient, when presented with a disease that does not have a clear cut treatment option, needs to collect all the information he can to define his options, the risks and benefits of those options, and the costs; then he has to make a decision and live with its consequences.

Life’s a bitch sometimes.  Making decisions is hard work and you know you’ll win some and some you’ll lose.  What’s important is being able to live with the results of the ones you lose.  If you did your best to answer all the questions, to weigh all the choices, you’ll be able to live with your losses.  If your decisions were ill-informed and hasty, not only will you have to live with your losses, you will have to live with regret, as well.

Until they invent a “retrospectoscope”, a man has to work hard to understand his situation, to know in his heart that what he chooses to do is right at the time, and to accept his account, whatever it is.

I’ve always said that, if you can make something good come from something bad, the bad wasn’t so bad after all.  Somebody once said, “man plans and G-d laughs”.  At least I’ve given G-d some good laughs over the years. 

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In the morning, I often feel like the pilot of a 747, getting ready to start up his engines and going through his pre-flight list.  Renee, my co-pilot, has her own list and, often, we check each other’s list.  It goes something like this:

“Gas, check, more than needed this am! 

“Fluids, check.  Better drain the system before it develops a leak.” 

“Waste dump, check.  Overdue by 3 days.  If not performed soon system will go critical.  Consider procedure 13, suppository.

“Landing gear, check.  Creaky but adequate.  Improve after first 10 steps.  Renee, where’s the Aleve?”

“Back, check.  Working good this am.”

“Neck, check.  Not working so good.  Where is the Aleve?”

“Heart, check.  BP, check.  Windshield, check and foggy.  Where are my glasses?”

Pilot to co-pilot, “All systems go.  Check your list.  Central computer, check. No headache.  Chassis, check.  No back pain.  Ventilation system, check.  No cough.  To hell with work, how about I take you out for a spin?”

“OK!, I’ll get serious. Time to wash this baby off and take off for the rest of today.”

  Sometimes, getting old can be complicated!

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The flowing article has been published several times over the past few years.  It is even more appropriate today than it has been in the past.

Originally published on March 5, 2011, this article ranks in my all-time top five viewed publications.  As insurance and Medicare become more restrictive, medical luxuries become more important.  With the recent move to brand many tests and interventions as unnecessary, what was once cutting edge and “necessary” now falls into the realm of luxury.  The statisticians look at what is “enough lives saved” in their quest to define necessary.  PSA screening is no longer “necessary” as not enough lives were saved for the cost of the test.  If your life is saved by a test of intervention, doesn’t that qualify as “enough?”  “Medical Luxuries” addresses the word “need.” 

The word “need” means different things to different people.  In an earlier article, I referred to “need” as the new four letter word.  People overuse and abuse the word “need”.  In my practice of medicine, I defined three levels of need. 

A level one need is critical and worth fighting over.  I saw level one needs two to three times a week.  Level one needs are exemplified by the 60-year-old hypertensive male who has chest pain.  He needs to be in the hospital now!  He needs to go by ambulance now!  His life depends on it.  When he refuses to follow my advice, I dial 911.  When he is at home and refuses to heed my advice, I call 911 and his wife.  Level one needs are absolute! 

Level two is where I spent the majority of my time.  My job was to inform you why you needed whatever it was you needed, what the benefits and risks were, what the expense was and how soon I think you should get it done.  I then left it up to you to decide if and when you were going to do it.  I might disagree with your decision but respected it.  A routine colonoscopy is the standard of care at the age of 50.  It is a level two need.  (If you have a family history of colon cancer, it is a level one need.) 

Level three needs are luxuries and the topic of tonight’s article.  Luxuries are needs you can do without but can do better with!  In medicine, a luxury is anything that is either unproven (but promising), not standard of care, or not covered by insurance.  We live in a peculiar world.  I have patients who won’t get a chest x-ray ($200) because their insurance won’t cover it.  They drive to the office in a BMW but won’t spend $200 on their own health.  I have patients who eat at expensive restaurants every weekend ($50 per person) yet want an inferior generic because the branded cost is $100 per month.  The insurance world has convinced us that if, they won’t pay for it, either you don’t need it or it is too expensive to afford.  

Luxuries can save you money and your life.  Several years ago, I was called in to the hospital to see a very sick patient at 5 a.m.  I dressed quickly, jumped into my car, backed out of the garage and slammed into my daughter’s car.  I had not spent the extra money to buy back up sensors when I purchased my car.  My decision had consequences.   I had to tell my daughter I smashed her car.  I had to pay for her repairs, as well as mine.  What seemed like a luxury item at the time turned out to be more of a necessity than I had anticipated and a costly error in judgment as well.  Luckily, the patient did fine. 

So what are luxury medical items?  Cardiac Scoring is a good example.  It measures the calcium load in your coronary arteries and predicts coronary artery disease.  A healthy 50-year-old male with no family history of heart disease is buying a luxury when he gets one.  Insurance won’t pay for it and technically he doesn’t need it.  So why get it?  Most of us are healthy until we are not.  If his results are normal, he gets peace of mind.  If his test is strongly positive (it happens to the healthiest of us), he may well have saved his life. 

Every year there are unexpected deaths in our community.  Could the purchase of a healthcare luxury, an annual physical, an EKG, blood test or x-ray, have saved their lives?   I would like to think so.  The next time your doc asks you to get a test or buy a medication that is not a covered benefit, think twice before you dismiss the idea.  Times are tough and money is tight; but, if your roof was leaking, you would find a way to get it repaired.  I often use analogies to make a point and my favorite has to do with your house.  Your house is very important; and, when it needs repairs, we find the means to do so.  Your house shelters your body; your body houses your soul.  Do everything you can to protect your body and keep it fit for many years to come. 

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Lose Lose Situation

Everyone has heard of the win-win scenario but what about the lose-lose scenario.  Imagine I just got off the phone with an unhappy patient.  He has had a very sore throat and a temperature of 99 degrees Fahrenheit for 24 hours.   He “knows” he needs an antibiotic and can’t come in to be seen.

“Doc, I know my body.  When I get a sore throat, I always need an antibiotic!”

“Mr. A, the vast majority of sore throats at your age are caused by viruses.  Antibiotics don’t kill viruses.  In reality, the risks of antibiotics far outweigh any potential benefit at this time.  Give it a few days.  Gargle with warm saltwater, drink plenty of fluids and take acetaminophen if your temp goes above 102.”

“Doc, I can’t afford to be sick.  It will ruin my weekend.  I know I need an antibiotic!” 

My patient does not sound happy.  He is sick and convinced that nothing short of an antibiotic will help.  What’s a doc to do?  The easiest thing is to give in and call his local pharmacy.  After all, what’s the worst that can happen?  He could have an allergic reaction or an antibiotic-induced diarrhea, that’s what!

What else could happen?  Frankly, he could get worse!  If anything, antibiotics mayl assist the virus in attacking its host by wiping out the patient’s normal flora.  What else could happen?  

By prescribing an antibiotic inappropriately, I will reinforce the idea that my patient needs an antibiotic every time he gets a sore throat.  The odds are strong that he’s going to get well; and, if I’ve given in, he will attribute his newfound health to the antibiotic.

In a future world where doc’s pay is dependent on patient satisfaction surveys, Docs will constantly be faced with this lose-lose scenario.  Is my job to satisfy my patient or to provide evidence-based, appropriate medical care?

Making matters worse, some urgent care doc, whose job is dependent on patient satisfaction surveys, will likely see my patient this weekend.  He/she will likely give in quickly and prescribe the antibiotic that I refused to prescribe.  He/she will enjoy the win-win of pleasing the patient in a 4-minute visit and will not have to deal with the aftermath.  So goes the life of a family doc.

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Below is a letter I wrote shortly before going on medical leave.

I’m angry.  I don’t like being angry.  Being angry is unhealthy and counterproductive.  Physicians are not supposed to get angry at their patients.  I can’t help it!  This week I’ve seen multiple patients for self-induced illnesses.  Health is a precious commodity and watching patients piss away their health makes me angry.

I’m supposed to repair the damage my patients are creating.  I’m supposed to perform that miracle without running all sorts of tests and without prescribing all kinds of expensive medications.  After all, Docs are accused of running unnecessary tests and prescribing expensive medications.  Aren’t they?

I’m also expected to deal with angry family members who, by law, aren’t privy to the facts of their loved one’s case.  All they know is their family member’s health is failing and it must be the doc’s fault or the medication’s fault.  They also complain about the cost of all the tests and treatments and specialists.

“Doc, you’re bankrupting my parents.  We can’t afford to pay their bills.  How did things get this bad?  You’ve taken care of my dad for 20 years.”

Exactly!  For 20 years, I’ve instructed my patient in the intricacies of diabetic care.  I’ve sent him to diabetic educators.  I’ve sent him to see a nutritionist.  I’ve provided literature.  I’ve explained that diabetics need to develop a Master’s level of education in the disease and manage themselves.  I’ve met with his wife and gone over things with her.  She’s tried to help but failed.  For 20 years, my patient has refused to do anything for himself!  The end result is not pretty.  It makes me angry.

It’s not just diabetes.  There’s the overweight hypertensive, basking in salt and lard whose family can’t understand why his kidneys are failing and why he’s had his third heart attack.  There’s the alcoholic who can’t understand why he’s so broke and can’t keep a job.  He refuses counseling:

“Doc, I can’t afford to see a counselor and I don’t have a drinking problem.  I’m just down on my luck!”

Of course, he can’t afford to see a counselor.  A fifth of booze a night plus a pack and a half of cigarettes eats up a lot of cash!

Wow, I feel better now that I’ve got that off my chest!  I can only do so much.  The person who has to care the most about my patient is my patient!  I can’t do it alone.  I can’t save a person from years of self-abuse.  

So, please help me help you!

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Yesterday, I promised to give you a gift today that would help you improve your medical care and wrest control from the insurance companies.  You can skip to the end of this article for your present or read on.  I suggest that you read the entire article first. 

Recently, one of my readers wrote the following:

“We were just discussing this at work.  The first consideration in medical is the expense and the hospital liability, rather than the patient. Also frustrating is that we all have teams of doctors that seem to never come together to talk about a patient and how best to treat the patient.  They all just do their specific part.”

Let me address this reader’s concerns line by line. 

“We were just discussing this at work.  The first consideration in medical is the expense and . . .. Expense is often the first concern of patients as well as doctors.”  

While patients pay a fortune to the insurance company to cover their care, they pay a pittance to the family doc or internist responsible for their care.  Patients, after reviewing their EOB (explanation of benefits), would often comment that I got ripped off (indeed I did).  Some would offer to pay the balance that my office was forced to write off.  By contract, we could not accept it.

“The first consideration in medical is the hospital liability, rather than the patient.”

Liability is a huge concern both for the patient and the doctor.  Malpractice insurance costs your doc tens of thousands of dollars.  We live in a litiginous society. Just look at the TV commercials where the lawyers tout the fact that their clients pay only if they collect. Bringing a frivolous lawsuit costs you nothing and, since defending against a frivolous suit can cost $50,000 or more, many docs will cut their losses and settle even though they did nothing wrong.  The cost of medical liability drives the cost of medical care in the U.S.  Even worse, the cost of practicing “defensive medicine” adds even more expense.

“We all have teams of doctors that seem to never come together to talk about a patient and how best to treat the patient.  They all just do their specific part.”

The Bears have a head coach who’s responsible for coordinating all elements of his team’s game.  He is a highly paid, respected (some years) individual.  Your family doc or internist is the head coach of your team.  He/she is not highly paid.  In fact, he/she receives nothing for the coordination of care that is so sorely missing in today’s medical world.

After a ten-hour day seeing patients, I would spend 2-3 hours on the phone with patients and specialists coordinating care and another hour or two reviewing letters from specialists:  yes, fourteen to sixteen-hour days were the usual.  The electronic medical record actually made the situation worse.  No longer to I receive succinct written correspondence.  Instead, I would have to review a 5-6-page document and glean out the pertinent facts.

Here’s your present.  FIND A CONCIERGE DOC!  In other words, hire a head coach who is responsible for your care and who is paid to manage your team. While you pay huge sums of money to your insurance company, they do not have your best interest in mind.  They do not pay your doc to manage your care.  Most pay for a 6-minute visit.

I loved my concierge practice and patients.  Most were not rich.  All believed that personally investing in their care was worth it.  I had Concierge hours set aside so that I would not be rushed.  My assistant coach, Ewa, carried the concierge phone and was available, like me, 24 hours a day. (Our Concierge patients loved her.) I never heard a complaint!  Practicing medicine with a group of patients who were truly dedicated to “Living Wellthy” was not only emotionally rewarding, but fun!

Currently, a new way of providing care is growing.  “Retainer” medicine and “Direct Primary Care” practices cost less than Concierge Medicine and offer savings on lab work and prescriptions as well as easy access to your doc/head coach.  Dr. Dan Di Iorio has established a hybrid practice in Barrington.  For more information on DPC click on his name and review his web site.

Have you ever heard, “You get what you pay for!”  It’s a lie.  With insurance, you don’t get what you pay for.  Often, you get f..ked.  With Concierge Medicine, you get what you pay for and it’s worth it.

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This is a complicated subject so bear with me while I give you a little historical background.  In “pre-conquest times” (the 80s), you were an individual by the name of Mr. P.  You would have established a direct relationship with my practice and my responsibility to you was clearly outlined by the Hippocratic Oath I took on graduating medical school.

You were responsible for following my medical advice and paying your bill.  I was your doctor and responsible for delivering the best medical care available.

My chart note would have started with something like this:

“Mr. P. is a 34-year-old white male, father of 3, executive, smoker, appearing healthy and slight overweight, here today for . . .   Appropriate lab was done and reviewed, and he was given a script for cefoxidril two times a day for 1 week and told to see me if he failed to improve. Counseling for smoking cession was begun.”

At checkout, you would be billed for a short visit and given follow up instructions.  You would have been asked to pay at the time of service; and in 1984 a short office visit would have cost you around $30 dollars plus the cost of your lab.  You would have been given an itemized bill for your records.

We, my patient and I, were responsible to each other.  There was no third party involved.  If you had insurance, you would deal with them directly.  I was free to deliver whatever care you needed or desired.

Now, flash forward to present time.  I refer to the present as “post-conquest” times. My profession came under attack in the 90s.  The enemy, the insurers of America, used an ancient trick to enslave us.  The “Trojan Horse,” known as Major Medical Insurance, promised to help you deal with catastrophic medical bills.  Things went downhill from there.  At first, the insurers offered docs contracted rates for their care.  Over time, they offered to cover more and more services and my patients, colleagues and I accepted their proposals. We were rounded up and lead into a pen and the gates were slammed behind us and padlocked.  

Physicians were no longer able to negotiate contracts.  Two “suits” came into my office and handed me a contract to sign.  They worked for one of the largest insurers.  I told them I would read it over and get back to them.  I’ll never forget their response. “Dr. Segal, you obviously don’t know who we are.  There are no negotiations!  Either sign this contract or lose 30% of your practice as we insure 30% of your patients.”

I reached into my desk and pulled out my recorder and asked them to repeat the threat.  I told them I was going to the State’s Attorney as I felt that I was being strong armed into signing their contract.  The only thing they said as they left was, “You’ll be sorry!”  They were right.  It took years for me to get a contract from them and the only way I could see their patients was to join a hospital-based group.  

Now, to get to my point.  In today’s world, I am no longer a doctor who works for you.  I am a provider of care covered under a contract that my patient (customer) purchased.  When you register, you are labeled as a PPO, PSO, HMO, Medicare or some other ridiculous abbreviation.  The letters assigned to your account determine what care you receive and who is truly in control.  There are now preferred labs, hospitals, specialists.  They are “preferred” by your insurer, not necessarily by your provider or you.  

Your office note is now computerized.  Your “provider” is paid based on the number of boxes he/she checks so they will spend a great deal of the visit checking boxes.  You are now a customer of XYZ Insurer and there is now a rule book that all involved in your care must follow.  

The note no longer says lab done but instead says ‘lab ordered at in network lab, to be reviewed at follow-up visit.”  Everything your provider does will be assessed by your insurer and accepted or rejected by them.  Your order for cefoxidril will be declined and the pharmacy will blackmail your provider into prescribing Amoxicillin.

The following is the conversation wherein your provider is blackmailed:

This is Paul, the pharmacist at ABC Pharmacy.  Cefoxidril is going to cost your patient $400 dollars and his insurance will provide Amoxicillin for $4.  Your patient can’t afford $400.  What do you want me to do.?”

Your provider chose generic cefoxidril as, theoretically, it has better coverage for what ails you.  However, $400 is absurd so he/she, weighing risk vs. benefit, makes the switch.  He/she will remember having to switch and, in the future, will save himself/herself extra work by prescribing the cheapest products possible according to your plan’s formulary.

At checkout, you are now a “99214” with a diagnosis code “J36.”  You are also a “F17.201”. Further, you are coded for a “99207 and a notation was added stating 14 minutes of which 50% was counseling was made.” 

 As your former doctor, I have been demoted to a provider and dehumanized.  I am now a trained monkey following the rules of my new master.  I am no longer paid for my services nor do I have the right to set my own value.  I am reimbursed, at a later date, at a rate set by my new masters.  Ultimately, I get paid the same $30 dollars I got in 1984 but I now have 4 employees in my coding and billing department driving down my income.

As a patient, you have been dehumanized into a series of checkmarks and codes that mean nothing to you.  You now pay a $20-dollar copay but get a bill for $250.  The insurers have purposefully driven up the LISTED COST OF CARE INSURING THAT YOU CAN’T SURVIVE WITHOUT THEM.

I seriously believe that today’s insurance industry is the legal branch of organized crime!  I have a present for those of you who read this article in its entirety.  Tomorrow, I’ll give you my solution.

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“Arlington Ford, can I help you?”

Customer – “The motor in my car is going Ping, Ping, Ping.  Can you tell me what’s wrong with it and what I can do to stop it?”

“Of course, we can.  Why don’t you make an appointment and we’ll have one of our mechanics look into it.”

Customer – “Can I talk to the mechanic?  I’m sure it’s nothing and he’ll be able to tell me what to do.”

“Our mechanics are all working on cars right now.  I’ll set up an appointment for you.”

Customer – “Can you have a mechanic call me on his break?  It will only take a minute.  I can’t come in.  My insurance only covers collision, I can’t take off any time from work, and I can’t afford to pay you.  I want to know if I can fix it.  Please have a mechanic call me.”

“I’ll have one of our service managers call you later today.”

Service Manager – “Mr. Ping, it’s really difficult to tell you what is pinging without checking over the car.”

Customer – “If you’ll just stay on the line, I’ll walk out to the car and turn it on.  You can listen over the phone.”

Service Manager – “Mr. Ping… walking sounds, door opening, car starting…Mr. Ping, I can’t hear anything and I have to help other customers.  I’ll put you through to the appointment desk, please hold.”

Customer – “You guys are all the same.  You just want me to come in so you can run a bunch of unnecessary tests and charge me a fortune!  I’ll drive down to the auto parts store and see if they can tell me want to do!”

Substitute doc for service manager and patient for customer and you have a true-life picture of an average day in the life of a doctor.  Just as listening to a ping over the phone is essentially worthless to a mechanic, trying to accurately diagnose an illness over the phone is as, well.  The difference is the mechanic who gives advise over the phone is not likely to make a fatal mistake.

If your body is pinging, bring it to a qualified doc.  Invest the time and money necessary to keep your body safe and healthy.

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“Medicare for all,” who are they kidding.  The medical world will never be free from the profit mongering insurance industry.  Upset about the cost of medical care?  Take one look at the profit statement of any health insurance company or Pharmacy Benefits Manager and you’ll realize where the real money is!  

For one moment, look beyond the insurer’s bottom line profit and look at their gross income.  Realize that there are thousands of people making billions of dollars running one of the largest bureaucracies in the world.  Now, add to those numbers the added overhead your doc shoulders in coders, billing staff, and time spent in prior authorization activities and you’ll realize why we have the most expensive medical system in the world. We also have the insurance industry feeding money into almost all of the political campaigns, assuring the continued control over healthcare in the US.

So, when I tell you I’m angry, you shouldn’t be surprised.  What you might find surprising, is why I’m angry today.  I’ve accepted the fact that my profession has been kidnapped by terrorist in the guise of insurers and Medicare.  I’ve accepted that we will forever be enslaved by those who steal our precious healthcare dollars all the while blaming the cost on those greedy, inefficient docs.  What I can’t accept is the human suffering caused by the insurer’s quest for ever growing profits.

With the New Year comes new formularies. Major Pharmacy Benefits managers (another name for insurer) will decide to take product number one off formulary and replace it with product number 2. All patients covered by their organization will be forced to change medications as of January first.  If my patient refuses to abandon the treatment that has worked well for him/her over the years, he/she will be forced to pay an exorbitant fee to continue on your current medication.

Why force a large number of patients to abandon their previously successful treatment and take a chance on getting ill?  PROFIT, pure and simple!  The insurer has found a way to cut its expense and is willing to potentially sacrifice the health of its customers for a larger profit margin! 

Unfortunately, patients will need to see their docs before starting on their new medicine and may well need to have multiple visits to the doc’s office before they are stable on their new medication.  Some will not do well on their new medication and some may even end up in the hospital.  

The pity of the matter is that to increase the Pharmacy Benefits Manager’s (PBM) profit, both the patient and the health insurance company that covers the patient’s office visits will be forced to incur the added expense associated with the medication change.

It’s utter madness!  We should all be sick of it!  Unfortunately, there is not much we can do about it and, next year, the PBM’s formulary is likely to change again.

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