How to save on health care costs

This lady wrote an article on how to save health care costs.

Articles like this always leave me split. The progressive in me says, "right on"; the physician in me says, "bullshit". There is a mixture of both in this article.

Firstly, unless you are a radiologist or a pathologist who owns a lab; you don't make money by ordering tests. If you are a radiologist or a pathologist you aren't allowed to order tests although certainly radiologists often come very close to doing so. I agree there are too many tests ordered and what she has cited certainly sounds eggregious. However as a nurse practitioner, she could simply look at the lab req. and tell her family doc, "no I don't want all these tests".

Likewise when she had the swollen knee, why didn't she just tell her FP, "all I want are some anti-inflammatories or physio". If her doctor is like me, he will find it a hell of lot easier to write an Rx for diclofenac than to fill out an MRI requisition.

There are some reasons why doctors like their patients to come in at regular intervals for prescription refills rather than phoning it in. In her case it sounds unnecessary but her FP probably can't tell the less controlled, less compliant diabetic in his practice, " You have to come in every 3 months but she doesn't" Actually he can. As someone who now takes regular medication, my FP also only gives me 3 months supply and won't refill over the phone. And it pisses me off. So I fax him to get past his secretary and he does a refill. Professional courtesy.

When I was an FP years ago and there was a small glut of FPs. Those of us starting our practices used to call patients in far more than necessary to build up their patient numbers. Now that there is a doctor shortage maybe this needs to be reviewed.

Salary?

25 years ago if you told me I was going to be on fee for service 25 years later, I would have said you are nuts. 25 years later, still on FFS.

No question salary would save $$$ possibly at the expense of patient care and convenience, however I am still waiting for an offer.

Love Boat

I posted a couple of weeks ago about a doctor who went off on holidays leaving her patient high and dry, and in narcotic withdrawal.

I wrote a letter to the doctor as a courtesy explaining what had happened and why I had written a prescription for her patient.

She wrote back explaining that she works a lot as cruise ship doctor and can't get a locum (or persuade the doctors she is in partnership with) to cover her practice. She also said she took this patient on as a "favour".

So.....

Somebody else didn't get into medical school and the taxpayers paid for 80% of the cost of educating you so you can work on the love boat and see patients as a favour into between cruises.

Like the title of this blog says:

I used to be disgusted......

Summertime Blues

I got a phone call the other week that I was expecting having gotten several every summer just about every year.

I practise chronic pain management part-time. In addition to sticking needles into people, I also prescribe medications. These include opioid medications. After a number of years, I realized that a significant number of my appointments were people whose only purpose was to get a refill of their opioid prescription. Don't get me wrong, in carefully selected patients (which of course describes all mine), opioids are the most appropriate way to manage chronic pain and most of those patients were doing well on the opioids. I was concerned that because I was using up valuable clinic time simply to see someone, ask them how they were doing and write them a prescription for what was often the same dose of the same drug they had been on for years, I was unable to see as many new patients and was not able to spend as much time with more complicated patients.

I therefore did the logical thing. I made up a form letter for their family doctor, explaining that their patient was on a stable dose of medication and that in order to free up pain clinic time I was asking that the the FP take over the prescribing. In almost every case the FP did.

Now however between June and September I can expect to get at least one phone call or visit from a patient asking for a prescription because their FP has gone on vacation (often for more than a couple of weeks) and either has no one covering his practice, has a locum who will not prescribe opioids, or has partners who will not prescribe opioids. As I have told some of these patients, these requests put me in a bit of a bind because I have no way of knowing whether the story they are telling me is true although I suspect it is.

The most recent lady is a lady from the north of the province where family docs last about a week. She was already on a fairly hefty dose of opioids when I first saw her in consult and because I accepted that she would probably have trouble getting the doctor of the week to prescribe for her, I wrote prescriptions for her for three years. Despite trials of other drugs she is more or less what I was on when I first saw her. There were problems because of the distance, and she missed some appointments especially in the winter and I had to fax in prescriptions which I find to be a hassle. (Narcotic prescriptions which are triplicate in our province cannot be phoned in).

Earlier this year she triumphantly told her that she had found a doctor in one of the larger towns about an hour away from her small town who had agreed to take over her care including writing the prescriptions. I breathed a sigh of relief.

Prematurely.

About two weeks ago I got about 4 messages on my voice mail followed by 2 or 3 direct calls to my cell phone, the number which she had somehow obtained. Seems her family doc had taken 4 weeks off and neither of her partners who either see the patient or write a prescription for the patient. The patient was now our of medications, going thru withdrawal and was unable to go to work (did I mention she was working full time?). I wasn't too please with the whole affair, I told her that doctors were obliged to cover their practices, and anyway didn't she realize that doctors also took summer vacations and shouldn't she have anticipated this? I did phone the FP's office to verify that she was indeed on vacation and to ask if one of the other docs could write a prescription for her. The receptionist told me that the other docs were only covering "Warfarin and lab results" and that anyway it was well known that this particular patient was double doctoring. I phone our College and got a copy of the narcotic profile which verified that the patient had in the last two years only got prescriptions from her new family doctor and from me. After this I faxed in a new prescription which I suspect I will be doing a few more times until either she dies or I retire.

This isn't the most egregious case. I once co-managed a patient with one of the FPs. The FP prescribed OxyContin and I did trigger point injections. This patient again was doing fine, working full-time etc. Until the FP decided to take the summer off to go to Europe with his wife. He is a good FP and got a locum. Our patient showed up for an appointment to get a refill of his OxyContin. The locum recoiled in horror, called up a psychiatrist who arranged for an emergency psychiatric admission. He was detoxed and discharged on diazepam, in my opinion a far more addictive medication. Nobody bothered calling me although my progress notes were all over his FP chart. I only learned of this when he showed up in August for his trigger point injections. I sent off a hopefully not too-tactfully worded letter to the doctors involved.

I have a methadone licence. When I first got it, I was the only doctor in the clinic who had one. In 1999 I took three weeks off and while my colleagues covered my practice, neither could write a methadone rx. Because of this, I and the unit clerk spent the two months prior my departure, trying to ensure that every patient on methadone would not run out while I was gone. We managed to cover every patient but one. And she complained to the College. And I got a phone call from the deputy registrar and an aural hand-slap. But that of course was 10 years ago.

Not enough information

I am a consultant. This means my job is to help other doctors with their patients. I am a little baffled by why other doctors perceive me as smarter than them in a least a very small way.

As a part-time chronic pain doctor, all my patients come to me by a referral.

Some chronic pain patients are very simple. I can take a history and examine them, come to a diagnosis and suggest or initiate treatment.

Most chronic pain patients are more complex. They have had a lot of procedures, medical trials and investigations. To properly assess this, I need to know what they have tried, for how long and in what dose. For example 100mg of gabapentin is a lot different than 3600 mg of gabapentin.

About a year ago, I saw a patient who had moved to town from another community. He had been getting injections with Botox from another doctor and wanted this continued as it seemed to have been working. He was however very vague about where or how much possibly due to a head injury or PTSD. Unfortunately the consult did not have much more than his name and healthcare number. A lot of times I can figure out what to do without my information. This patient wasn't one of those times.

Anyway I took the initiative to call the other doctor up and either discuss the patient or get the file.

This doctor as it turned out has the receptionist we all hate. She answered the phone, "Dr. X's office can you hold" and before I could reply, I was on hold. I put my phone on speaker and killed time for 10 minutes before I hung up and dialed again. The same thing happened. The third time I was ready and was able to interrupt her. I told her who I was, that I would like to talk to her doctor, that I knew she was busy and that I could give him a number to call at his convenience (GPs can actually bill the healthcare system for such phone calls). She just said, "well we're busy" and put me on hold again.

I therefore gave up trying to talk to this doctor or for that matter his receptionist. I dictated a letter and I asked for a copy of his records on this patient. I had told the patient that when I got the letter I would call him in for treatment.

Months passed. Every once in a while, usually while somebody else had me on hold, I would think about the case.

I came in this morning and found a handwritten note from the patient asking why several months later I had still not treated him. Apparently he had showed up the evening before in very bad humour and hassled the receptionist about why I hadn't seen him.

Any in a few weeks I will try to muddle my way thru a very unhappy patient.

Now in the 15 or so years that I have been seeing patients, this lack of documentation has been a major problem for me. When I worked at of CofE we actually designed a form where we asked for more information and would not book the patient until we had received the information. The thing is, most doctors offices have fax machines now; it is a simple matter to fax the rel event documents. It would take a secretary less than a minute. I know this because I frequently fax stuff myself (I thought it was neat when I learned to use a fax 10 years ago).

Almost worse than the family doctors are specialists who refuse to send you a copy of their consults when the family doctor either hasn't or can't send you a copy. Next to them are the family doctors who copy their entire chart so I have to sift thru the pap smear results to find the MRI report. Hospitals now seem to put their records on micro-film after about two years and actually ask you to come down and look for the records on the little micro-film viewer.

The monthly newsletter our friendly college puts out actually has a letters section. About a year ago, a family doctor actually wrote a letter to complain about the bad specialists who were demanding he send them information so that they could actually do a proper assessment on the patients he sent them. Now I would have thought that this would merit a public written tongue lashing from the registrar but it was in fact just published without comment.

(I should note that I did after I posted this (after I sent off an angry letter to the FP copied to the college) that I got an appologetic letter from the FP along with the info requested.)