WhiteCoat

I’m Not Paying For It …

Gramma WhiteCoat is getting foot surgery this week. She’s in her Golden Years, so her care is paid for courtesy of the Medicare National Bank.

I spoke to her last week and she stated that she was examined by 4 different doctors, 2 nurse practitioners and 3 nurses for preoperative procedures. Her primary care physician (not one of the 4 doctors providing a preoperative exam) saw her about a month prior to her surgery, cleared her for surgery, and ordered preoperative labs. Because the labs were more than 3 weeks old, the surgeon wouldn’t accept the normal results and ordered a second set of preoperative labs.

Grandma WhiteCoat’s response: “I know they’re doing all these exams and blood tests to pad the bill. But I don’t care — I’m not paying for it.”

From the mouth of my own mother.

Just another example of why any system in which the consumer has no stake in cost containment is doomed to fail.

FREE = MORE

Patients must have some skin in the game in order for any medical system to work.

43 Responses to “I’m Not Paying For It …”

  1. Matt says:

    Sounds like the real problem is physicians doing “work” to pad the bill, not patients.

    • WhiteCoat says:

      Sounds more like defensive medicine to me.
      No doctor wants a lawyer with a “retrospectoscope” to accuse the doctor of relying on “outdated” labs or of not having umpteen different consults to medically clear the patient just in case there is a bad outcome during surgery.
      Have to provide the best care someone else can pay for, you know.

      • Matt says:

        Is “defensive medicine” the new euphemism for physicians padding their bottom line?

        Oh, and considering your relative paid taxes all those years, she’s actually getting care SHE paid for.

      • WhiteCoat says:

        I won’t engage someone who has such a limited capacity for logic.
        However, I do find it amusing that you take the assumptions of my elderly mother who has no knowledge of medicine as gospel truth when it suits your needs, yet you discount everything I state about the interface between law and medicine because you ASS-U-me that all physicians know nothing about law.
        You also ASS-U-me that the physicians were not providing medically appropriate care. Using your logic, how would you – as a lawyer, or my mother – as a layperson, know anything about appropriate medical care? Why should anyone at all listen to a lawyer’s comments about medical care?
        You also ASS-U-me that my mother worked and paid Medicare taxes all of her life which is another incorrect assumption.
        The point of the post was not to comment about the medical care.
        The point of the post was to show that a system that provides unlimited and costly care with no checks and balances on spending is unsustainable.

  2. that’s why I spend most of my day taking care of hospice patients disguised as full codes…families want everything done in a very expensive exercise in futility.I work in a unit geared toward toward the geriatric patient in the hospital setting and it’s frightening. Daily we snatch people back from their eternal reward. I can guarantee you most of our admits have at least one consult because there are always co-morbidities that will flare up. The labs, tests and procedures multiply like rabbits. Most of the time it’s the families driving this process because grandma hasn’t been coherent in years. It’s not only sucking the life out of the medicare tit, it’s cruel. As an ICU nurse said to me, “corpses on ventilators.” So we pay and they stay.

    • k says:

      “Corpses on ventilators” – sounds like one of those “K” brand vent farms that are so prolific in this area.

  3. no she’s not, matt, some labs, an ekg and a cxr would just about eat up all she paid in. If people got out what they paid in, this wouldn’t be an issue. do your math.

  4. Matt says:

    “However, I do find it amusing that you take the assumptions of my elderly mother who has no knowledge of medicine as gospel truth when it suits your needs,”

    YOU took her statements and extrapolated them into some larger comment on the state of medicine, and now I’m wrong for doing the same?

    “You also ASS-U-me that the physicians were not providing medically appropriate care.”

    Actually, that was your assumption since your post ASS-U-mes that if she had skin in the game all these things wouldn’t have been done. I was simply positing that if you were correct, and you’re the doctor after all, then perhaps there was another reason for it.

    ” Why should anyone at all listen to a lawyer’s comments about medical care?”

    They shouldn’t.

    “The point of the post was to show that a system that provides unlimited and costly care with no checks and balances on spending is unsustainable.”

    To reach that conclusion, you have to take a position one way or the other if all those actions were necessary. If they were, then what’s your beef? What’s more, we don’t know how much it costs, or if her lifetime of taxes have paid for this many times over.

    However, even if the patient did know what everything cost, they would still be relying upon the physician, the professional, to tell them what was necessary because they don’t know off the top of their heads, particularly with surgical procedures, what is necessary. In the same way if you were to hire an attorney, you would rely on them to not waste your money on actions that weren’t necessary to achieve the desired result. The professional is who the client puts their trust in, and is for the most part the cost gatekeeper.

    So the question falls back to you – do you think all those actions were medically necessary or not?

    • WhiteCoat says:

      You have used the term “necessary” four times in this post and have challenged me to determine whether actions were “medically necessary”.
      Define those terms as you have used them so that I can give you an appropriate answer.

      • Matt says:

        Good question. I would define the term “necessary” as treatment needed to fix the problem. Your implication, and correct me if I’m wrong, was that if your mom had more skin in the game (and presumably knew what exactly she needed to get the specific problem fixed) she would have declined some of the treatment she received, as it was unnecessary. I’ve defined “necessary” as best I can, but with your superior knowledge in the field, you may well disagree, so educate me on it.

        BTW, I’m not “challenging” you, I’m asking.

      • WhiteCoat says:

        Your definition assumes that a “problem” exists and that the “problem” needs to be fixed.
        Using that definition, diagnostic testing would be “UNnecessary” since no problem yet exists.
        Admissions to rule out coronary disease in a patient with chest pain who really has gastroesophageal reflux would be unnecessary because cardiac testing does not “fix” the problem of reflux, nor does it “fix” the problem of chest pain.
        Any testing or procedures performed in which no “problem” is found (i.e. “exploratory surgery” or “screening colonoscopies”) would also be unnecessary since no “problem” ever existed.
        Also, extensive joint replacement surgeries to repair minor osteoarthritic changes causing minimal pain would be deemed “necessary” because they “fix” the problem of osteoarthritic pain.
        Want to try again with the definition of the terms as you are using them?

  5. Matt says:

    And really, to change any of this, YOU, the provider, have to leave your current payment model. Until you leave the insurance/govt reimbursement schedule, nothing much will change. Although I can see why you don’t want to leave it, at least you know those entities will likely always be solvent. Plus physicians have made a pretty fine living over the years using that model.

  6. what a great pissing contest…balls in your court wc.:) (no pun intended)

  7. pelican says:

    Actually, the answer to this particular conundrum is pretty much Defensive Medicine.

    I worked for 10 years in a hospital in the States, now I’m working in Canada- where care is free to the patient, but “loser pays” is the rule in civil suits, and malpractice suits are rare and regulated.

    And in Canada, whether or not your mom would have had her bloodwork re-done would be determined by nothing other than whether she had some kind of relevant potential turn-for-the-worse in the three intervening weeks. The only docs involved in her care would be her “family doc” and her surgeon.

    Yes, the US and Canadian systems are different in other ways, and there are pros and cons for both systems. But, in this particular example, it’s all about the need for defensive medicine in the States- patient “skin in the game” has nothing to do with it.

    And, seriously … even if your mom had to pay for the extra tests, realistically, how could she refuse them as wasteful? How would she know, without you telling her? What are the little old ladies whose kids aren’t docs supposed to do? And, do you know a US surgeon who’d operate on a patient who was refusing reasonable preoperative tests, in what sounds like a non-urgent situation? Talk about red flag for potential litigation! S/he’d document your mom’s refusal up the wazoo and turf her so fast!

    Part of the solution to the health care situation in the States is going to need to be serious med-mal reform.

    PS … WhiteCoat, dude … don’t feed the troll.

    • Matt says:

      “I worked for 10 years in a hospital in the States, now I’m working in Canada- where care is free to the patient, but “loser pays” is the rule in civil suits, and malpractice suits are rare and regulated.”

      Another legal genius. A version of loser pays exists in the US in almost every state. And the Canadians do not have a pure “you lose-you pay” system.

      ” it’s all about the need for defensive medicine in the States- patient “skin in the game” has nothing to do with it.”

      How can you say there is a “need” for defensive medicine if you have no idea if your defensive actions actually reduce your exposure?

      • Whitecoatneedstocomedowntoearth says:

        Whitecoat – There is no such structure of “loser pays” in medical malpractice cases in the United States. The Canadian physician meant that the plaintiff must pay the medical bills of the physician if the plaintiff is unsuccessful. In the U.S., the plaintiff does not suffer any financial loss (particularly in contingent fee cases) and therefore suffers no consequences if he or she sues and loses. I think the implementation of such system would be a disaster for patients. How about laying off the lawyers and making it more difficult to become a doctor? If the doctors weren’t fucking up, then there would be no payments in lawsuits…

      • WhiteCoat says:

        You’re attributing Matt’s comments to me. I haven’t said anything about the “loser pays” system in this post.
        However, I think that a loser pays system in the US would go a long way towards curbing inappropriate lawsuits. It would make people think long and hard about the merits of their suit before running to the courthouse. Right now, plaintiffs only look at the “upside” of what could happen if they win since there is no “downside.” Matt’s assertion that a “loser pays” system is in place in the US is not entirely true since the cost shifting in this country is discretionary and not mandatory. A friend of mine forwarded me an e-mail not too long ago where her attorney stated that the costs of *defending* a case that was a defense verdict totaled more than $1 million.
        As for making it more difficult to become a doctor, do you want more quality and even less access? With all the budget cuts, administrative hassles, liability, debt, etc., being a doctor isn’t as popular as it once was. I have a friend who is dean of a medical school who told me that their admission standards have decreased significantly because they can’t find sufficient applicants who met their former standards that will fill their open slots.
        As for doctors who “fuck up,” there are 1 billion patient visits in the US each year. What rate of “error” should be acceptable?

  8. Nurse K says:

    I don’t have anything ultra-substantive to add to the conversation other than the fact that Happy has a picture of his sweater-clad dog’s wang up at the top of his blog, which limits his credibility somewhat.

    What I wonder is why she can’t just get a foot procedure with a local block if she’s such a huge surgical risk, but that’s just me.

  9. Matt says:

    “Your definition assumes that a “problem” exists and that the “problem” needs to be fixed.”

    I ASS-U-med that there was a problem that led to her needing foot surgery. Was that incorrect? I have no problem with including the testing required to diagnose the problem in with the necessary definition.

    “Want to try again with the definition of the terms as you are using them?”

    I can try all day long, but again you’re the medical expert, so please, give me your definition. I was following your implication that if she knew more about what was going on and its cost (“had some skin in the game”), she would decline some of these tests as they were not particularly necessary (or whatever term you want to use). Were you not implying that?

    • WhiteCoat says:

      You are the one who repeatedly used the terms “necessary” and “medically necessary”. I’m simply asking you to define them as you have used them in this context. You flip the terms around freely, yet you seem to have difficulty defining them.
      If someone with a post-secondary education can’t define the terms he is using, then why should anyone believe anything he is saying?

      The “skin in the game” comment refers to consumers weighing the cost and benefit of testing or treatments. Just like consumers weigh the cost/benefit of other services. Is it worth it to get the “deluxe” carpet cleaning with stain protectant or should I just save the extra $200? Should I pay an extra $1500 for leather seats or just go with cloth in my new car?
      In the medical arena, patients would ask it worth $1500 to get an MRI to see what is causing my shoulder pain or should I just use NSAIDs and see what happens? Is it worth $10,000 to fix bunions or should I just take pain medications and live with the pain? Do I need the latest and greatest hypertension medication for $200/month or can I live with $4/month medication that works almost as good?
      Read the link that was provided in the original post.

      And don’t forget to define “medically necessary” – I’m still waiting so that I can provide you with an answer to your challenge, er, um, question.

      • Matt says:

        “You flip the terms around freely, yet you seem to have difficulty defining them.”

        No difficulty – every time I put a definition out there you tell me it’s no good. So I leave it to you. Were you not implying that some of the care your mother received was unnecessary? If it was truly necessary, why would her having skin in the game make a difference?

        “The “skin in the game” comment refers to consumers weighing the cost and benefit of testing or treatments.”

        Problem with your analogy is that those aren’t professional services. How can a consumer weigh the cost-benefit? It’s not like the physicians asked her. You don’t get paid to sit around and discuss it with them, so you just act and we, as non-physicians, rely on your professional judgment.

  10. ERDoc says:

    Matt you are ill informed if you believe physicians order extra tests to “pad their bottom line”. In most settings, physicians make no additional income for ordering more tests.

    I once had a patient accuse me of trying to make extra money for myself by ordering an X Ray. It’s laughable.

    Now if you are in a clinic setting and you own the lab and X Ray equipment, perhaps this is a different story.

    WC makes a good point with this post. I wouldn’t call repeating these labs unreasonable. Elderly people can have electrolye imbalances which can develop over a few short weeks. Glucose or creatinine could be bumped in a short time frame. Likely not, but worth checking a few pre-op labs.

    The real question becomes, why were they done three weeks in advance of the procedure if they were for “pre op” purposes?

    Communication and efforts to reduce expenses by physicians could have saved a little money here, if anything. But physicians aren’t trained to practice “cost effective” medicine, we are trained to practice good medicine and keep people alive.

    • Matt says:

      ” I wouldn’t call repeating these labs unreasonable.”

      OK, I agree with you then. So why would mom having skin in the game matter, if the physician would tell her these were reasonable tests?

      “But physicians aren’t trained to practice “cost effective” medicine”

      More accurately, you’re not incentivized to practice cost effective medicine. And for that matter, “cost effective medicine” and “good medicine” are not necessarily mutually exclusive are they?

  11. Nurse K says:

    In our hospital, the ER docs make more money for more tests…it’s a combo of hours worked and RVUs (if you order a lot of tests or even an unnecessary saline lock, your patient is more acute and you get more money). This particular combo lends itself to layzee doctors ordering a lot of tests on few patients, IMHO. If you’re not layzee and efficient in my hospital, it’s usually because you want to be that way philosophically. You’re not otherwise rewarded for it.

  12. hashmd says:

    In many cases it is some regulatory body that indirectly determined that lab done 3 weeks earlier as pre-op were not “acceptable”. Just like the Joint says an H & P done more than 72 hrs prior to surgery must be updated or reaffirmed by the operating surgeon. This drives up the cost.

    When I do a Pre-op exam, I no longer do lab or X ray because I know that will be done within the week prior to surgery. As I don’t own a lab or X ray facility, I gain no monetary reward at all for such. The reason I even do the exam is at the request of the surgeon to assess for fitness for surgery. If they have cardiac issues or of the age or other risk factors for cardiac disease, I skip the exam and send them to a Cardiologist for clearance since that is what the ANESTHESIOLOGIST wants prior to surgery. (Hey, they don’t like people coding on the table any more than the surgeon does).

    Defensive medicine? Perhaps. But I do it to ensure someone thought about it prior to surgery on MY patient. We have stopped a number of surgeries because of occult cardiac problems found during these exams.

    Do I do it for every type of surgery? NO. For foot surgery likely to be done under regional blocks, I wouldn’t.

    It is called medical judgement. Some of us still use it.

    • WhiteCoat says:

      It’s not my intent to put Grandma WhiteCoat’s medical problems or the care provided by the physicians on trial in this post.
      I’m saying nothing about the medical appropriateness of her care because I don’t even know the physicians who examined her.
      As for labs, I don’t see what would have changed in three weeks if her labs have been stable, but everyone practices medicine a little differently.
      The whole point of the post is to illustrate how people don’t care about the costs associated with care when the care is provided to them for free. See psycho therapist’s example below as well.

  13. LH says:

    Ok, so there’s been a lot of explanation here so far about what goes into doctors’ decisions on what tests to order. WhiteCoat, are you saying that what I, a non-physician, should be doing is second-guessing my doctor when he orders tests for me? The point has been made several times here that it’s not to the doctor’s monetary benefit to order my tests, and so, going on that, I can only assume that my doctor ordered the tests because he believes I need them. Why would I question him, since he knows medicine and I don’t?

    I understand what you’re saying that patients should have some responsibility in what’s going on — they should. But I’m failing to understand how it can possibly logically work to rest the responsibility of whether tests/treatments should be happening squarely on patients’ shoulders.

    • WhiteCoat says:

      It depends. You can choose to be an educated consumer or you can settle into learned helplessness.
      When you purchase a car, do you research it first or just go pick one off the lot?
      When you go to a movie, do you look at the reviews first?
      Do you have someone inspect a home before you purchase it?
      Most people do all of these things. But no one seems to care that they pay $200+ per month for designer blood pressure medications when $4 WalMart prescriptions work just as well in most circumstances. Why? No skin in the game. Insurance pays for all but the copay.
      If you’re unconscious or dying, you can’t question the physicians. There isn’t time. But if you have cancer, do you get a second opinion on treatment? If you have a non-urgent surgery, do you get a second opinion? If not, you should.
      People don’t question their doctors, but they should.
      Why are you ordering that test? What is the likelihood that it will help diagnose a problem? How could it change the treatment plan? What are all the risks involved? What is your “differential diagnosis”? How much will this prescription cost me?(I’ll bet 90% of doctors couldn’t answer that question for a majority of medications they prescribe) Is there a cheaper alternative to this medication? Get the information and go learn about it online. Heck, the sites on my “Links” page will give you more information than most doctors will give you and many of the sites are free.
      The answer is that yes you can and should question your doctor and the doctor should take the time to answer your questions. Teamwork will be more important than ever once rationing becomes more prevalent.

  14. First, in response to your point regarding the level of personal financial investment in treatment and overall participation as well as overall system efficacy…

    I meet few folks who continue psychotherapy after their no-sweat-to-me Medical Assistance ends (for whatever reason) and Medicare assumes the primary payor status demanding a patient co-pay. Out-of-pocket costs are amazing in their rapid healing properties.

    Second,
    To reach that conclusion, you have to take a position one way or the other if all those actions were necessary. If they were, then what’s your beef?

    Matt, are all your actions on this site necessary? Necessary If so, what’s your beef? If not, what are you doing, what are your intentions?

    And, the best for last:
    BTW, I’m not “challenging” you, I’m asking.

    Spoken like a true Axis II, be it disorder or character trait.

    React away, counselor.

    PS, WC? I hope you and Matt are really friends and are deliberately and playfully engaging in this activity to keep your audience entertained.

    • WhiteCoat says:

      No, not scripted. Was amusing this morning. Now the moment’s gone.

      • Matt says:

        Yup. And while we might be friends if we had, we’ve really never met outside this forum. This is just idle discussion of issues, dancing around the fundamental one.

  15. Keith says:

    That surgeon is behind the times in terms of preoperative workup and assessment. Would fit that he is an orthopod or a podiatrist.

  16. ERP says:

    What was your response?

  17. Matt says:

    I’m glad WhiteCoat posted the below statements, because they illustrate a number of common misconceptions of doctors about legal issues.

    “However, I think that a loser pays system in the US would go a long way towards curbing inappropriate lawsuits.”

    If by inappropriate, you mean people with less money than their opponent would have to think hard regardless of merit, particularly in close cases, then yes, probably true. But again, we already have loser pays.

    “Right now, plaintiffs only look at the “upside” of what could happen if they win since there is no “downside.””

    A very common misconception that illustrates that the writer doesn’t understand the economics of the contingency fee. While there may be no downside for the plaintiff in terms of cost, there certainly is with regard to the stress of a case, which physicians say is significant. However, for a lawyer operating on a contingency fee, there is a huge downside, particularly in med mal cases. There is the out of pocket cost for expenses, usually in the tens of thousands. Plus, and physicians don’t bill hourly so they don’t understand the value of time as well as they should, there are the hundreds if not thousands of hours spent preparing for and trying a case. And of course your standard overhead continues while you’re not making money. It makes little sense to spend that time and money on questionable cases when you could be spending it on ones that pay as when your time is what you are selling, you are generally very careful with that commodity. Does that mean dogs don’t get filed? No, but there is a significant economic disincentive.

    “Matt’s assertion that a “loser pays” system is in place in the US is not entirely true since the cost shifting in this country is discretionary and not mandatory.”

    This is an incorrect statement, as an offer of judgment can very much make it mandatory. It also assumes that other countries have it as a mandatory provision. Also incorrect. Not to mention that the reality is, particularly for a seriously injured med mal patient, that if they can’t work and can’t pay their medical bills already, the other side’s attorney fees are the least of their worries.

    “A friend of mine forwarded me an e-mail not too long ago where her attorney stated that the costs of *defending* a case that was a defense verdict totaled more than $1 million.”

    Couple of things here. One, it illustrates our willingness to believe any claim that supports our pre-existing beliefs while we apply rigorous questioning to those that don’t. Two, if true, this was almost certainly not a single plaintiff, single lawyer, personal injury case. If it was a business litigation matter involving billions, it wouldn’t be surprising. If it was a class action, it wouldn’t be surprising, particularly if the parties are using large firms where the first year associates start billing at $300/hr. And we don’t know if the judge in the case DID order fees and costs to be paid. Of course, neither of those have any relation to medical malpractice, so they’re not really relevant to this discussion.

    “As for doctors who “fuck up,” there are 1 billion patient visits in the US each year. What rate of “error” should be acceptable?”

    This is an interesting stat. Whitecoat, I’ve heard you and others say that there are too many malpractice claims. How many are there and how many would you expect based on that level of interaction between patients and doctors?

  18. cynic says:

    Too many lawyers, not enough lions

  19. C. says:

    Im going to weigh in here on both accounts as a legal professional, a patient and well, let’s face it a reasonable person.

    There really is no argument that medicine is a litigious area, however the question is what is reasonable? In medicine there are incompetent, careless doctors, nurses, PA’s, techs, etc., and there always will be. Is it reasonable to sue a physician for not being able to foresee a patient having a heart attack 10 days post from having a mole removed? Speaking reasonably, having no history or current indication of such, the answer is no. is it reasonable to sue a doctor for amputating a limb when a mole was supposed to be removed? I would think yes. Much of the current medical litigation is fueled by the legal community. I have been home mending for the last 10 weeks and the number of commercials for attorneys on daytime tv is astounding. Side effects from medication, an unexpected outcome from a medical procedure, not happy about the wait at your doctor’s office? SUE! The attorney’s who are paying for these commercials are more than likely far more educated than their target clients and let’s face it, if someone is home and awake during the day watching tv, it is more likely than not that they are unemployed and less educated (unless of course, one has broken their fibula). I suspect there will be some some flack from Matt, but let me remind that I am a legal professional and still agree with the medical community.

    Now, for skin. My skin is so far in the game, it’s being sloughed off. I pay full freight for my medical insurance and let me say the coverage is less than stellar. WC is correct in the idea of a P&L on the part of patients. Currently I pay a monthly premium for my insurance in addition to the co-pays and all the procedures and equipment the insurance company doesnt cover AND I pay into medicare. Medical coverage isnt free, someone is always paying and wouldnt it be nice if patients thought beyond themselves and consider the impact on those that are paying. WC’s mom isnt receiving services she paid for, she is receiving services current taxpayers paid for. The issue is systemic and though the idea was good, the implementation of Medicare is flawed.

    My father is a life long smoker; 50 years of smoking 2+ packs a day. His medical bills far exceed what he has paid into Medicare and his private insurance combined for HIS LIFETIME. When I see someone casually smoking it infuriates me that I, at some point will be paying for their ridiculous, notoriously bad behavior. My insurance premiums continue to increase year over year, while my coverage declines due to little if any fault of my own as a relatively healthy 34yo female who makes a conscious effort to sustain good health.

    As previously mentioned, I recently broke my right fibula, chipped the talus bone and tore the deltoid ligaments. Hospitalized for 3 days, surgery, hardware, the whole deal. The insurance company declined the claim. After faithfully paying, the 30k bill was denied and I was saddled with the bill, only after much grief and strife was the bill partially covered by insurance. The accident, through no fault of my own was denied when I was responsible and procured coverage specifically for something of this nature.

    I do question the number of xrays prescribed and the number of PT visits (seems a little low), because I know come January, my premium is going up, it is just a matter of how much. My scripts are filled generically if possible because I pay the difference between generic and brand names. What the hell do I care if the script is Percocet or Roxcet? Just kill the damn pain. Patients should be given an itemized bill for all procedures and visits whether covered privately, or publicly. $1800 for a stainless steel plate and 7 screws?? The anesthesiologist charged the same, now which one is inflated?

    • WhiteCoat says:

      I agree with everything you’ve said.
      Note your statement “My scripts are filled generically if possible because I pay the difference between generic and brand names.” You are an educated consumer because you choose not to pay hundreds of dollars more for a prescription that does the same thing as a generic. That’s market forces at work. You are making my point for me.
      Itemized bills = market forces at work. Patients can compare costs.
      People’s attitudes are going to change because more and more costs of medical care will land on the shoulders of the patient. Two options will be bankruptcy (only available every 7 years I believe) or paying the bill. When people know they will be responsible for the bill, their cost-consciousness will change dramatically. If and when people start being turned away for care (or given appointments for care at “free” clinics 6 months in the future), the value of medical care will become much more evident.

      • Matt says:

        “People’s attitudes are going to change because more and more costs of medical care will land on the shoulders of the patient.”

        If you believe this, you are not listening to the President. The cost of care is going to be shifted to ALL taxpayers, not the individual patient. While you’re pussyfooting with legal matters, the freight train of universal care is going to run you over. And you, the medical professional who deals with it day in and day out, are going to be the one most impacted. And likely not in a positive way, unless you have an unhealthy love of bureaucracy.

    • C. says:

      Yes, bankruptcy is every 7 years, dependent on a judges discretion.

  20. Matt says:

    “I suspect there will be some some flack from Matt, but let me remind that I am a legal professional and still agree with the medical community”

    You’re not going to catch flack from me being against some of the advertising. I am too. I would never argue there are not excesses that could be curbed. My position is that allowing lobbyists to arbitrarily decide the value of an injury without hearing the evidence or regardless of fault is simply the wrong way to do it. You’re just hurting the weakest among us to save insurers a few dollars. That is where I and the good doctor get sideways.

    By the way, what does “legal professional” mean? I’m guessing it doesn’t mean lawyer.

  21. Matt says:

    By the way, WhiteCoat, you don’t have to just believe me in response to this statement of yours:

    ““Right now, plaintiffs only look at the “upside” of what could happen if they win since there is no “downside.””

    You can also refer to the 2006 NEJM study by Dr. David Studdert and others, which is probably the most comprehensive study of malpractice litigation ever, wherein the study notes:

    “The profile of non-error claims we observed does not square with the notion of opportunistic trial lawyers pursuing questionable lawsuits in circumstances in which their chances of winning are reasonable and prospective returns in the event of a win are high. Rather, our findings underscore how difficult it may be for plaintiffs and their attorneys to discern what has happened before the initiation of a claim and the acquisition of knowledge that comes from the investigations, consultation with experts, and sharing of information that litigation triggers.”

    http://content.nejm.org/cgi/content/full/354/19/2024

  22. C. says:

    Matt, I am in fact an attorney.

  23. Lynn B says:

    So, way back to “are the tests indicated? ” We as internists get a lot of pushback against doing ANYTHING, and like whitecoats family , lots of other people seeing the patient.

    This is a story from the other testing extreme. I had a patient who fell, and hurt her neck. Fell off the porch of a local charity. Their liabilty insurance will pay for the fall 100% , but not for routine care. Late 70’s with diabetes , hep C from an MVA related transfusion, hypertension, high cholesterol, good labs and BP . Brought to her friends favorite neurosurgeon in another town (the one here is a jerk, and she wasn’t going back after I sent her) .Pain getting better, she stops coming in for this after 2 visits, cancels one of her q 3 month regular visits.

    Anesthesiologist, blesss his heart called me with questions one day pre-op . I had no clue surgery was scheduled .No pre-op eval done except by a wellmeaning neurosurgical PA. No tests, just the required H and P . Day of surgery , in Afib, not known to have this, referred , not to me, to a cardiologist who says “she has chronic heart failure from valve disease” , EF is 20%. Too bad he did not see the 3 years ago EF of 58% with no valve disease, even though he requested the records (another issue there ) . Now this is my fault per family and neurosurgeon, who I have yet to meet , speak to, or see any recods from …..yet another issue . Ultimately the cardiologist said surgery was OK, not knowing her neck and arm symptoms were almost all gone. Her neurosurgery visits were being driven by the fact someone else was going to pay for surgery.
    Hope someone , since she fired me, eventually looks to see if she had a big silent MI with annular dilatation , not that she is surgical candidate any more.

    The appropriate test was an H and P with her PCP. That made no money for the other hospital’s lab, and perhaps the PA’s fees for the H and P go to the neurosurgeon. Unclear.
    So who suffered? The poor patient.

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