A recent article on KEVINMD.COM entitled, “Keep your medical insurance, but pay the doctor with cash,” was of particular interest to me.  My practice was unique in that I ran a Concierge practice side by side with a typical fee for service practice.  Comparing the two practices is easy.

The Concierge practice was fun.  If I needed a test or procedure, I could order it without hassles.  Concierge patients bought their freedom by paying cash and appreciated the care they received.  For the most part, my Concierge patients were not wealthy.  Instead, they were hard-working middle-class individuals who prioritized their health above all else.

Fee for service/insured patients relied on their insurance companies and gave up their freedom trading it for a copay.  Their care carried more overhead than the Concierge patients and they really didn’t appreciate how much back office work it took just to get them an x-ray.

You may not know it, but your doctor’s office is forced into taking insurance products and putting up with the insurers’ discounts.  Did you ever stop to think that your doctor is your banker, carrying your debt until the insurance company pays him/her?  Did you realize that your $20-$40 copay represented the majority of your doctor’s income?  I bet you didn’t know that it cost me $10 every time I sent you a bill.

Giving a discount for cash paying patients makes sense.  The only drawback is a theoretical one.  Medicare and your insurance company could look at your doctors’ discounted fee as his/her real fee and claim that your doc over charged them.  Medicare could then claim that your bills were fraudulent and file criminal charges against your doc.  Sound insane? It is!

My suggestion is that, if possible, pay cash and ask for a discount.  In lieu of paying for your whole visit, make sure that your account is zero’d out every time prior to leaving the office. Recognize that if your insurance company requires “prior authorization” that it requires extra work and expense.  Make sure you show your appreciation.  A cake, cookies, etc. says thank you.

Personally, I think tipping your provider is appropriate but I’m in the minority!  Things are different today as many docs work for large corporations.  A five-star review says thanks in an acceptable way.

Frankly, I think it’s best to look for a concierge practice.    However you do it, don’t forget to say thanks.

Here’s today’s joke:

A man was admitted to hospital today with twenty-five toy horses stuffed up his rectum. doctors have listed his condition as ‘stable’.


The art of listening is a critical skill, not just in medicine but in all of life.  I expected some blow back from my last article as I inferred that finding a doc who would take the time to listen to you was both important and a difficult task.  After all, we all listen to you, don’t we?

Not really!  In my day, there was a study that showed that docs interrupted their patients’ telling of their stoies within seconds to minutes of entering the room.    Tuesday, I had two doctor appointments.  In both cases, a physician extender took my history without ever looking at me.  The assistant interfaced with the computer, not me.  My morning appointment was with the neurologist, and she not only listened to me, but reviewed her assistant’s note.

My second appointment was with the eye doc.  Again, as is the usual, a physician extender questioned me.  Unlike the first appointment, the eye doc flew through the door, did not introduce himself, examined me and left.  He did not review his assistant’s note nor expand on it[Ss1] . He did not question me.

Now I’m sure there was an occasional patient who complained that I did not listen; but, for the most part, I interviewed the patient.  It was my responsibility to obtain a thorough history and my staff’s responsibility to note why the patient was in the office, knowing that I would build on the note they left me.

It was also my responsibility to provide for the patient’s needs as best I could and, if I could not, to know who could.  Sure, there were patients who had needs I could not meet, patients who were angry, frustrated and felt wronged; but, in all but one case, I was able to defuse the situation and help the patient find specialists who might better deal with their problems.

Yesterday’s article was on chronic pain, as is this one.  The number one cause for a dissatisfied patient is chronic pain.  It is also where listening is the most important.  Sometimes, treating chronic pain involves a bit of negotiation.  There is often a gap between the patient’s needs and the treatment options.  Sometimes, the only option is to live with pain, in which case a therapist skilled in helping individuals live with their disabilities is helpful.

Recommending a pain “psychologist” often elicits anger as the patient immediately responds that the pain is real, not in his mind.  Chronic pain is always real, is always a complex mixture of physical and emotional, and needs a combined approach.  When my back flares, the pain affects all of me. 

One thing I know for sure.  Shooting up a physician’s office, murdering the doc and his staff, is not a solution! If you have chronic pain and your doc is not meeting your needs for whatever reason, find a specialist who can help you.  If, like me, you have to live with pain, look to the alternative world for possible solutions.  If you are in Illinois, you might consider medical marijuana or its derivatives.

One last point, pain not only affects you; it affects your family and friends.  They may need assistance as well. What about the drug seeker/addict?  They are sick and need care also.  They often go from office to office when, in actuality, they need a referral to a rehab facility that will address the psychological and physical needs of drug addiction.

Here is today’s joke:

I asked my wife to rate my listening skills and she said, “You’re an 8 on a scale of 10.”

I still don’t get why she wanted me to urinate on a skeleton…


Chronic Pain

The problem with being an old, retired family doc is that, as your patients age along with you, your former patients die.  Years ago, I wrote an article about Ron’s hands.  Ron died on Tuesday; and even though I had not seen him since moving to North Carolina, I felt the loss. 

Ron was a paint contractor and jack of all trades.  In my hallway is the first piece of furniture I built.  I built it in his basement, under his tutelage.   Ron’s gift was his ability to make something out of nothing and examples of his work were present in my home and office.  Ron will be missed by many.

I have written several articles about the damage a physical job like Ron’s causes.  My carpenters, roofers, painters, etc.  built the homes and offices the rest of us lived and worked in.  Unfortunately, while building the structures we thrived in, they often injured their bodies, the cumulative effect leaving joint and back pain, as well as lung disease.  Convincing a young, healthy, strong craftsman that he needs to be cautious, wear protective gear and get help lifting heavy objects is not easy.

The result of years’ worth of repetitive injuries is chronic pain; and, unfortunately, current medical wisdom is to resist the use of “pain pills” and instead to treat the individual as if he/she was a “drug seeker” or had “psychosomatic” or “functional” pain.  So, what do you do if you find yourself in chronic pain from work related injuries and can’t find a doc who will treat your symptoms?

The answer is simple if you can get the doc to spend a few extra minutes listening to you.  Bring some of your tools with you.  Have your doc use a hydraulic impact hammer for a minute or two and then explain that you used it for 30 years.  A minute or two should cause a little discomfort and go a long way towards helping your physician understand the source and intensity of your problem. 

Each trade has its own culprits, so prior to seeing your doc spend a little time working on your presentation.  In 1984, I helped build my office.  I cut and installed ceiling tiles.  I did not wear a mask and quickly learned how necessary a mask was (I could have spat enough crap out of my airway to make a tile).  It was a valuable lesson.

I cut and installed the tile floors.  I did not wear knee guards.  Another valuable lesson.  I limped for weeks.  Cutting the wood for my furniture led to tendonitis.  Each experience helped me understand my patients’ pathologies and formulate treatment options.

Now all you must do is help your physician see your pain through your eyes.  Good luck.

Here is todays joke:

A sperm donor, a carpenter and Julius Caesar walked into a bar:

He came, he saw, he conquered.

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