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.

Friday, March 27, 2009

Pneumonia on a Budget

Saw a guy today with no insurance, plus fever, chills and productive cough. His chest sounded clear and his oxygen wasn't too bad (95% sat on room air) but he looked really crappy, so I sent him for a chest x-ray and gave him a prescription for clarithromycin 500 BID for 10 days. As it happened, the x-ray came back positive for pneumonia with a patchy right upper lobe infiltrate, so I told him to be sure to fill and finish the antibiotic.

How much did the day cost him?

I told him I could easily have buffed the chart to justify a level 3 visit ($70) (or even a 4 for $100) but my usual practice for the uninsured is to bump it down a notch.

My charge: $55.00

Instead of sending him to the hospital for the x-ray, I sent him to a new free-standing radiology facility that charges the uninsured only 10% over what Medicare would pay.

Chest x-ray: $62.00

One of the local supermarkets is running a special on free antibiotics. Unfortunately, the one I wrote for isn't on that list, and they wanted $78 for it. He called CVS and their price was $92. He went to Costco instead.

Antibiotics: $17.00

If my math is right, that comes to $134.00 grand total for medical care for today's diagnosis and treatment of pneumonia. What this demonstrates is that there are options for economical medical care with no sacrifice in quality. (Levaquin, another antibiotic commonly prescribed for outpatient pneumonia, is hideously expensive, typically costing $10-$15 per pill. Not only that, but it isn't even the best choice in terms of antimicrobial coverage for community-aquired pneumonia.) That total also comes to a fraction of what a monthly health insurance premium would cost him.

It just goes to show that even in this day and age of "broken" health care, there are bargains available for the savvy doctors and patients who know where to find them.


At Sat Mar 28, 12:53:00 AM, Anonymous Anonymous said...

Wow, my doctor's level 4 cost is $200 (internist).

At Sat Mar 28, 01:23:00 AM, Anonymous Anonymous said...

Thank you Dino for treating the uninsured like humans, and helping them both with their medical needs, and in terms of not slamming them with huge bills.
I was uninsured for a while and had a hard time even finding a doctor who would see me. My orthopedic surgeon, who had happily seen me and operated on me twice while I was insured, now refused to even see me in the office!! I was humiliated, and felt pretty worthless. Luckily I had a PCP who kindly treated me for free, and only charged me for actual costs (like a vaccine, or sutures).

Being uninsured is awful, and people like you are too rare.

At Sat Mar 28, 03:00:00 AM, Blogger Clinton said...

My impression is that part of the resistance to treat uninsured patients is similar to the concept of opting out of vaccines.

With vaccines: On the one hand, you have public health and on the other, a miniscule personal risk (or for your child) of a complication.

With the uninsured: On the one hand, you have a pool of cash to be distributed on a need basis and onn the other, an individual who won't buy in so they can save all of their money to spend on themselves (with a miniscule personal risk of financial ruin if something catastrophic happens.)

The question that you pose (which I hesitantly ask): If everyone decided that they didn't want to pay a premium and go for a pay-by-service plan... what would happen to the rates for the rest?

At Sat Mar 28, 03:27:00 AM, Anonymous James said...

Oh man. I feel like we have way more than enough to learn in order to graduate from residency and pass the boards without having to learn what everything costs as well!

At Sat Mar 28, 07:45:00 AM, Blogger Evil Transport Lady said...

I also thank you! My kids will be uninsured very shortly, due to age limits etc. Thanks for helping that guy out! Now he'll be able to recover at home and not the hospital!

At Sat Mar 28, 11:51:00 AM, Blogger Gino Dagnino said...

A long time ago that the proteins are talking about may be the solution to cure cancer and so far only in studies is that while throwing certain messages are not to sure of the exact cure for this disease, they said that the cells mother does it, but nobody shows yet why? That is to spend millions of dollars they say, find cures for diseases and so far nothing at all, "I think this is really a surplus and a disgrace to humanity, because there are many people who suffer from worry and no government to find solutions, just think personally and not to benefit the health of peoples and of millions of people suffering from this terrible pain, he says hopefully assessment is that the cure, it is just that, proposing solutions and not line their pockets with the pain of many people .....

At Sat Mar 28, 11:55:00 AM, Anonymous Anonymous said...

You are a very rare bird (dino?) in today's practice of medicine! Most doctors don't care and charge the uninsured many times what they are willing to accept from insurance companies. I've always wondered how someone who is in a helping profession could do this with good conscience! If one is willing to accept $80 from an insurance co. why isn't their fee (for a basic ov) $80 for all? (I know, I know, some MD is going to come on this site to comment that I don't understand the economics of a medical office...)
Bravo, good doc! We could use more like you!!

At Sat Mar 28, 12:54:00 PM, Anonymous Anonymous said...

I am curious why you sent him for an x ray. Your clinical experience and knowledge pointed you to the diagnosis. I understand that it is not good practice to treat illnesses with antibiotics "just in case" it is bacterial but my thought is that you could have saved him $62 by going with your intuition alone.

I'm a physician from Canada- the only direct cost to my patient for an xray is just their time waiting at the radiology dept. Still I don't send every one I treat.

At Sat Mar 28, 07:28:00 PM, Anonymous Anonymous said...

Doxycycline and tetracycline are viable options for CAP without comorbidities and are on the $4 list as many pharmacies. Is there any reason why you selected clarithromycin over a tetracycline?

At Mon Mar 30, 03:45:00 AM, Anonymous Anonymous said...

Here in SoCal where I live, I've found more often than not, docs in outpatient settings, like you, are VERY willing to help trim down costs when they know you are uninsured. Things like bumping the acuity level DOWN, not charging for ear lavage, bags full of samples, and discounting cash payments. Thank you thank you thank you

At Mon Mar 30, 05:02:00 PM, Blogger scalpel said...

In the ER he'd probably be charged around $2000:

ER physician level 4 charge: $400
ER level 3 facility fee: $675
CXR plus Radiologist fee: $400
CBC, chemistry panel, blood cultures times two: more $
IV antibiotic and oral antipyretic of choice: more $
pulse oximetry, IV supplies: more $

Moral: don't get sick after office hours

At Tue Mar 31, 09:21:00 PM, Anonymous Anonymous said...

Assumptions, assumptions. No one knows if the fellow had recently lost his job or even perhaps been unemployed for several months.
My hats off to you for doing the right thing, let's hope it didn't keep food off of a table for 4 people though. We really do need to have a better health care system.

At Thu Apr 02, 09:18:00 AM, Anonymous Chris said...

Thank you for being a caring human being and (it sure sounds like) an excellent doctor. I think we need to put YOU in charge of the nation's healthcare system - obviously, you have the common sense to figure out how to 1) cut costs, and 2) still give good care, SIMULTANEOUSLY. Amazing. Keep up the good work (and please tell me where you are so I can move there).

At Fri Apr 03, 07:58:00 AM, Anonymous Anonymous said...

Dino, that was a very smarth thing to do and it was in the best interest of the patient.

Here is another cost saving example. My child is on a feeding tube with pump. My co-pay for a month's supply of the bags from the DME provider is $123.00. I can buy the same number of bags, new, on ebay for just $20.00. Guess where I buy them?

At Sun Apr 12, 01:19:00 PM, Anonymous red rabbit said...

Consultation: $
CXR: $
Treatment: $

Finding a physician who's a humanist: priceless.

Having moved from Quebec (where prescription drug insurance is mandatory) to Ontario (where it is linked to your job), I am dealing with more and more patients who can't afford their treatments. We supply samples as much as we can, but I'd hate to have to deal with an entire medical system like that. Bravo for doing it so carefully.


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