I got a flat tire this weekend.  There were clues that I chose to ignore - the alignment going out suddenly, the steering wheel jiggling when I drove - but the sudden thwacking sound as I sped down I-20 was a clue I couldn't ignore.  I pulled off, then unknowingly stood in a fire ant bed while I changed my tire.  It still itches.  That's not the point of this post, but I just needed to gripe a little.

Yesterday we went to the tire shop and found out that not only were both of my front tires worn out, but my rear tires were old and cracked - at least that is what the guy told me.  I went ahead and changed all four tires, leaving the car at the shop for the morning.  About two hours later I got a call, saying that my brake fluid was "really bad," and that I also needed an air filter changed.  I was suspicious, but I did know I needed the filter, and the charge wasn't that much.

Car repair places are like this for me.  It always seems that they find something new wrong with my car that needs fixing.  I go in thinking I am going to spend X dollars, and end up spending 2X.  The problem is that I can't do without the car, and I don't know enough about cars to do the work myself.  This ignorance causes me to put off getting things fixed on my car, as I don't like spending money beyond expected.  I don't wait for the "check engine" light to come on, but the fear of expense, along with the fear of repair men taking advantage of me, keeps me away from auto repair shops.

Sound familiar?

It takes circumstances like this to remind me that my patients can feel the same way.  They come into my office and I order tests, find problems, send them for consults, and prescribe medications.  What would be a relatively inexpensive visit ends up being quite expensive.  Then I tell the patient they need to come back in a month, and they look at me with pleading eyes and ask: "could you make that two months?"

The big difference between me and the car repair place is that most of the ways I rack up the patient's bill is by sending people other places.  I don't increase my profits by referring the person to cardiology or by ordering an MRI scan.  I do get a little of the suspicion when I schedule follow-up, but hopefully patients don't see me as suspiciously as I see the car repairman.  But I am positive that people cancel follow-up visits, avoid preventive care, and don't take medicines because they don't think it's worth the cost.

This is the achilles heel of procedure-based billing.  If I get paid more for doing more, I am financially motivated to do something that may or may not be also motivated by medical need.  Once I come under suspicion of putting my financial interest above the patient's medical interest, the foundation of care, trust, is undermined.

The decision as to what is necessary and what is not isn't as clear as it seems.  We used to have access to x-ray equipment for which we made profit from each x-ray we ordered.  To be financially viable, we had to order a certain number of tests, and we would profit significantly by doing even more.  A funny thing happened: I ordered more x-rays.  People with a cough, who I would have previously just watched now got an x-ray.  People with ankle sprains got x-rays as well.  I never ordered them frivolously, but I became increasingly uneasy with the increase.

We no longer do x-rays, and we do only a few lab tests in the office (mainly for convenience).  Many (most?) of my colleagues, however, have bought in to this system that rewards doing more.  Hospital-owned practices exist so that the doctors will order ancillary tests and procedures at their facility.  This is the system that has put down primary care - one that devalues the office visit - and yet we buy into it to offset this devaluation.  Thus far, our office has done quite well without, but the lure of new well-reimbursed procedures is always there.

Some have touted a free-market system where docs post their fees and are paid cash for what they do.  Some feel the solution is the HSA account that pays from a tax-sheltered fund for care.  But I wonder if any cost containment will ever be possible with a system that pays more for quantity, but less for quality.  In this kind of system, the patient is in charge of cost-containement, by rejecting care offered them, by questioning the motives of doctors, and by waiting until small problems become big problems.

It's very hard, if not impossible, for patients to know if what  is being done is actually necessary.  I don't know if I really needed my brake fluid changed; I'll never know.  But I did wait until the tire blew on I-20.

And those ant bites really itch.

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