Medical Tuesday Blog

Medical Autonomy

May 22

Written by: Del Meyer
05/22/2017 3:32 AM 

There has been some confusion in this era with Personal Health Records with getting the patient more involved in his or her own care. Some patients have interpreted this as going to any doctor they feel they need at the moment. They do not see their personal physician as being their managing partner—but just a person they can see when all else fails and they don’t know which doctor they should see next. They don’t feel that cost should be a factor. They have no concept of the costs involve. They consider it as just another office call with a new or different doctor. One patient this week said it didn’t matter since she had Tri-Care, which allowed her to seen anyone she desires without authorization.

She had seen two new physicians since her previous evaluation. She had developed a cough with the phlegm clearing after a course of antibiotics. However, it did not clear her otherwise hacking cough. The allergist had done a pulmonary function test but she had no idea how well she did or what it showed. But she did begin allergy injections which over two months had no effect on her cough nor was it expected to do so in two months.  The printout from our HMO suggests that each consultation, which usually requires additional lab tests, x-rays, or procedures, adds $1500 to $3500 to that patient’s medical costs.

She also had two urgent care visits since her last evaluation in our office. Urgent care center evaluation is by another new physician who makes a stab at the diagnosis in the minimal amount of time without benefit of the patient’s medical records. Hence, these evaluations have minimal value depending on how many tests previously done have been duplicated. This is also a costly and essentially unnecessary expense.

She also had a hospital emergency room visit and was given another antibiotic. In the absence of any phlegm, this also had no significant effect on her cough. She developed nausea and vomiting the second day and call the Emergency Department. She was told there were no other antibiotics and she should see her personal physician.

The hospital Emergency Department visits start at $600 in our community but frequently can be as high as $9000. The ER doctor does not have the benefit of the patient’s medical file which may have been developed over the course of years with numerous tests, x-rays and probable procedures which the patient may not recall during an emergency evaluation, and even if recalled, is not able to give a medically verifiable result.

As a Pulmonologist I felt somewhat frustrated to not have basic pulmonary data to confirm my diagnosis to chart her treatment. Should I repeat the PFT or treat her empirically? Her cough of several months duration, persisting through two doctors, two urgent care centers, and one emergency room, had not stopped the coughing.

The diagnosis should have been obvious. In a lady with allergic rhinitis (hay fever) who develops a cough, it more likely than not is allergic bronchitis sometimes called cough variant asthma. Examination did confirm asthma. She did not have her albuterol inhaler with her and didn’t have any idea that she should carry it with her at all times.

So we used a new inhaler in our office. She was advised to exhale fully, open her mouth wide, and take a deep breath as I gave her an albuterol spray which she inhaled. I quickly reminded her that she must hold her breath for 30 to 60 seconds. If she exhaled the albuterol, it obviously would not do her any good outside her lungs. She was able to hold it for 45 seconds. She was then given the second inhalation of albuterol and was able to hold it for 60 seconds.

She had not further coughing during the remainder of her evaluation.

She was advised in the future to see her personal pulmonologist before the $10,000 to $15,000 she cost her insurance company over the past two months which are the ones who pay their Blue Cross premiums for such gluttonous use of health insurance which then increases their premiums unnecessarily. She already had an albuterol inhaler and we advised her to use every time she coughed. Hence, our $150 office call which required no further prescriptions was more effective than the $15,000 she had incurred.

We reminded her that we are always able to see established patients with 48 hours of their call and none of her health care visits were emergencies. In fact, none of her health care visits were effective.

She had not told any of these doctors who her personal physician was. Hence, we had no reports from any of them and so they were irrelevant to her. She was told to have a report in our office before her next visit from all her doctors or we would withdraw from her care. We would not be party to such a flagrant abuse of health care resources.

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In this case it would have saved more than $10,000.

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