Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, February 11, 2008

Seven of Nine; Not Bad

Thanks to an Israeli med student who sent me this link to "Nine Secrets Health Insurers Don’t Want You to Know." No offense to Jeri Ryan, but aside from two whoppers, much of the advice seems sound to me.

Here are the nine points:
  1. Don’t pay if you don’t have a say.
  2. You may be eligible for more coverage.
  3. To get tested, talk up your symptoms.
  4. Stall first, answer questions later.
  5. Letters are your best bet.
  6. Doctors can be good weapons.
  7. A little research can go a long way.
  8. There are ways to get drugs cheaper.
  9. An advocate can help you win.
I don't much care for the phrasing of #6; I think it would be more accurate to call us "advocates," but I suppose they want to save that word for #9. #8 is based on the somewhat insulting assumption that doctors are powerless against pharma assimilation; (resistance isn't futile at all.) But the downright insulting ones are #3 and #7.

Here's what they mean by "talk up your symptoms" in #3:
Your insurer doesn’t want to pay for a colonoscopy if it’s not necessary. But if your best friend is diagnosed with colon cancer and you want the $675 test to put your mind at ease, here’s how to get one covered: Mention to your doctor that you’ve had some blood in your stool and a lot of gas lately—or simply that your bowel habits have changed. Your plan has to pay for the test if you have gastro complaints, health experts say. (Only 21 states require insurers to cover colonoscopies for general screening.)
In other words, lie to the doctor. Very bad idea.

It is MY JOB to put your mind at ease. Never mind about paying for an unnecessary procedure; trust me: you DON'T want to have a colonoscopy unless you really need it. Too many people seem to feel it is their responsibility to diagnose themselves, decide what treatment they need and then simply convince the doctor to provide it. Not so fast. An intelligent patient with the internet at his or her disposal can sometimes do a half-decent job performing those tasks, but certainly not always! (Please note my willingness to admit that not every patient and not every problem require my full expertise and experience to bear on them.) Still, I'm far more than a rubber stamp. Accurate diagnosis -- and therefore effective treatment -- depends first and foremost on patient history. Never "talk up your symptoms" trying to tell a doctor what you think he ought to hear. Never. Please. Not only does it seriously undermine your treatment now, but by destroying your doctor's trust in your accuracy as a historian, he will never be quite sure of you. Believe me; you don't want that. You wouldn't want your doctor lying to you; why should we tolerate it from you?

#7, "A little research can go a long way," is along the same lines:
If you want a special CT scan or MRI, your doc probably won’t authorize it unless it’s an absolute must. Persuade her with expert info from the American College of Radiology’s Appropriateness Criteria, says Anne Roberts, executive vice chair of the department of radiology at the University of California, San Diego. Used primarily by doctors but open to the public, it’s an up-to-date list of the types of imaging that are right for various conditions. (Ed: The link in the article doesn't work, but this one does.) Arming yourself with the info doesn’t guarantee coverage, but it’s a proactive step in the right direction.
News flash: you cannot have ANY diagnostic test just because you "want" it. Ever. Damn straight I won't "authorize" it (actually, I "order" tests; insurance companies "authorize" payment for them) unless you really need it. Trust me: you don't want the excess radiation; the hours stuck immobile in a tiny tube, whatever the procedure is if it's not medically necessary. Once again, it is MY JOB to figure out what is wrong with you (or what may be wrong) -- which requires accurate information from YOU -- and what to do about it, including ordering any tests. It is also MY JOB to "put your mind at ease" if the likelihood of some condition you're worrying about is so low it doesn't warrant an expensive test.

MY JOB. The fact that other docs may do it badly does not change MY JOB one iota.

But the rest of the article seems to have some good points.


At Mon Feb 11, 07:38:00 AM, Blogger MedStudentGod (MSG) said...

Personally I think these kinds of articles are extremely harmful to the doctor-patient relationship. It's telling patients that you lie to get what you want and letting physicians know that you can't trust patients anymore. How is something like this beneficial to the public?

Having a well-informed and proactive patient is a good thing, but when it crosses boundaries like those in the article and that you highlighted it's less proactive and more like fraud. What the patient needs to understand is that the doctor, not the patient, takes the blame for a procedure not needed or if a complication occurs. I agree with you 100% Dino, it's YOUR JOB to determine is these are necessary - not an internet search engine.

At Mon Feb 11, 09:47:00 AM, Blogger William the Coroner said...

Damn straight. You are not a protein robot, a pharmacy vending machine. Don't act like one, and Don't Effing lie to me!

At Mon Feb 11, 10:23:00 AM, Anonymous Anonymous said...

Last visit to the doctor I told him: Insurance has got us both by the tail, doesn't it? He agreed.

At Mon Feb 11, 11:20:00 AM, Blogger janemariemd said...

I agree with your comments, but also with MSG (above). I would have liked the article to talk about personal responsibility for health, and about how there are NO PERFECT TESTS out there, that are 100% accurate, always normal in healthy people, always abnormal in the sick ones, etc. The article seems to suggest that patients are entitled to demand the latest, greatest-seeming technology. So far I've managed to avoid ordering whole-body PET scans and CT scans of the chest for lung cancer screening, but sometimes these conversations are challenging because patients feel like they ought to have them, and I do worry that I could be in trouble if something bad turns up in the future. I do seem to spend alot of my time talking elderly men out of PSAs, and healthy young women out of CA-125s, also. The latter, in particular, come in to my office with a printout from the Web about an ovarian cancer survivor who was vaguely symptomatic prior to her diagnosis and who states she should have had a CA-125 at some early point in her history.

Thanks for stopping by my blog, by the way!

At Tue Feb 12, 04:32:00 PM, Blogger Bookhorde said...

Check this out

At Tue Feb 12, 09:28:00 PM, Blogger Doctor David said...

I'm damned glad I found your blog! I couldn't agree with you more. Especially "a little research..." After all, I spent all those years in med school, residency, and fellowship learning how to take a history, perform a physical examination, formulate a differential diagnosis, order tests, evaluate their results, arrive at a diagnosis, recommend treatment, and evaluate the response to treatment. An educated patient is great to work with, and there are great resources on the internet, but if you think you can spend a couple hours on the web and be able to do my job as well as I do it, well... you're wrong.

At Wed Feb 13, 10:54:00 AM, Anonymous Anonymous said...

God help us when we try to circumvent the docs. Like someone said, y'all did the schooling, so who knows better? Do you suppose it's because insurance companies look for every way possible to not approve payment that have forced people to be, ah, creative? If so, these folks are going about it all wrong.

At Wed Feb 13, 04:19:00 PM, Anonymous Anonymous said...

When you say it is "My job" to order appropriate tests for patients, etc., I have to conclude you are interpolating, and that you think you are speaking for other doctors at large.

For years, I had been catching every virus that went around. I had yearly pneumonias and frequent hospitalizations, once for bronchitis and pleurisy. I gently suggested to my doctor of fifteen years that I would like to be tested for an immune deficiency.

He did everything but role his eyes when he wrote up the lab order. When the results came in, he left a message on my answering machine to call a specialist in allergy and immunology. He didn't even bother to tell me what I had.

I asked his office to fax me my lab results. A little research on the web indicated CVID, a self-diagnosis confirmed by Stanford when I decided to bypass our local specialist and shoot for the best care I could think of.

My G.P. never even apologized for having failed to order an immune panel years earlier. It was HIS JOB to think of this, not mine. He failed me, and he is otherwise an excellent doctor. Sometimes, a patient simply has to take charge of their own treatment. Not all of us are trying to manipulate the system by inventing symptoms to get our doctors to order unnecessary tests.

Frankly, I resent your attitude. I find it paternalistic and atavistic. I would have hoped medical training would have come farther than this by now.

At Wed Feb 13, 05:44:00 PM, Blogger #1 Dinosaur said...

Anon 4:19: I agree your doc failed you, but I would argue apples and oranges between lying about blood in your stool to get a colonoscopy to "ease your mind" and a failed diagnosis from a long-term doc. Your doc was an ass both for the way he handled the (missed) diagnosis and for not apologizing to you. All bets about ordering tests are off in the light of actual symptoms.

At Wed Feb 13, 09:44:00 PM, Anonymous Anonymous said...


Thank you for your comments about my missed diagnosis. That was not the only time that doctor missed a diagnosis of mine. Rightly, he is no longer my PCP.


At Sun Feb 17, 04:40:00 PM, Anonymous Anonymous said...

This illustrates the very worst of the American medical system. There is seriously no other country in the world where this is considered acceptable. They actually say "Your insurer doesn’t want to pay for a colonoscopy if it’s not necessary". THEY SHOULDN'T!!!!! Do you think that 700 dollars appears from the ETHER? Why do you think your insurance premiums go up every month? God, I'm almost looking forward to single payer to at least see the end of this.

One of the concepts we discussed during all that wasted time in medical school was specificity and sensitivity. Are the writers of this article going to take responsibility for every unnecessary surgical biopsy due to a questionable finding in a patient with no indications for testing? Are they going to take responsibility for every person subjected to unnecessary radiation? Apparently Google School of Medicine didn't address the topic of false positives.


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