My recent post on the patient who thought I wasn't worth paying caused a lot of discussion.  Most of it focused on the financial stresses of a patient in our system - something I am all too well aware of.  But some commenters (one in particular) felt that I was being excessive in my requirements for the patient.

While I think the person was way off-base in their comments, it did get me thinking about a difficult topic: how much is too much?  How often does a person need to come back, and when does bringing people back for frequent follow-up become excessive?  Some psychiatrists bring patients back every month for prescription refills, even patients who are stable.  I've had patients complain about physical therapists and even chiropractors who bring them back for multiple visits, incurring multiple charges to the patient.  These may all have merit (I certainly understand the psychiatrist's perspective), but in each case I have had patients suggest that the clinicians were bringing them back to make more money.

The more I thought about this, the more I realized that there is definitely cause for concern that docs may bring people back to ensure a full schedule.  Since my schedule is full and my income is adequate, I have no need or desire to generate more business than I already have.  I have practiced for fifteen years, so I seldom have a slow day.  This makes the temptation to bring people in these grey areas much lower.  But there certainly are times when people complain about us "forcing" them to come in to be seen.  These areas include:

  • Obvious symptoms of a urinary tract infection
  • Sinus symptoms
  • Allergy symptoms requiring prescription medications
  • Acne

Our policy is that we are unwilling to call in antibiotics unless there is a sore throat  and fever associated with exposure to a documented case of strep in the house (seen in our office).  That is our policy, but reality says that the policy gets bent on a regular basis.  If I know a woman has frequent UTI's, I sometimes will call in a prescription.  Overall, however, we stick by these rules because we are taking the risk of prescribing a medication, and have often found unexpected findings (such as high blood pressure or wheezing) in cases that sound straightforward.

But how often should a diabetic get seen?  I go a maximum of 6 months for the stable type-2 diabetic, although I usually do every 3 or 4 months.  What about the person with hypertension?  I like to see them every 6 months, but I do sometimes flex to 12 months for the particularly stable patient.  Do I fault people who are more rigid with their guidelines?  Not at all.  Even other physicians within my own practice are more rigid than I am on seeing patients.  I have the biggest practice, though, and so am trying to get everyone seen.

When copays were only $10 or $20, people didn't argue much with being brought in more frequently.  Now that deductibles and copays are high, the frequency of complaints is much greater.  Ideally, the decision would have nothing to do with the charge, but would be based on what was medically right.  But medical rightness is a very subjective thing, and many doctors will have different standards.  When I get patients from other practices, they often have to adjust to our more rigid rules.  Sometimes they complain, and occasionally they leave to find a doctor who doesn't force them to come in.

I have enough patients now that I don't worry about such things.  I practice in a way that I think is best for my patients and have enough business that I don't have to generate my own business.

Still, would it be better if primary care was cheaper?  I am not sure.  A bad consequence of the $10 copay days is that patients began to think we were worth only $10.  The disconnect of people from the true cost of care made them much more likely to be high-utilizers.  In an ideal world, I would only be driven to see patients based on their medical needs, and patients would trust that this was the case.  But we don't live in an ideal world.

We don't even live in a mediocre world.  That means that the argument and misunderstanding will rage on until...well...until the politicians can fix healthcare.

I haven't heard the weather forecast lately, but I don't think hell is getting any cold fronts soon.

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