Doctoring Health Care Health Care Reform inflammation


The man on the other line sits in a cubicle in a far-away city.

He is a physician, another “provider,” as we are called on their website.  The accent is British (how ironic), and his voice suggests to a trained observer, he is older.

All I wanted to do was a simple stress test with an ultrasound.  The patient, an overworked woman who devotes her life to the spiritual needs of others, presents with an arrhythmia. The irregular heartbeat scared her.  This I can see, because, well, I am seeing her as a patient.

The arrhythmia in question was in a grey area.  It’s nature was not so minor that I was comfortable dismissing it with pure, old-fashioned reassurance, which I do a lot, and in doing so more than my peers, always had hoped that when I needed said imaging study, a pass would be available.  Like the free sandwich notion: with every 12 patients reassured with simple doctoring (when others would order many more expensive tests), you get one free pass on the next grey-area patient.  

“Dr Mandrola, compared to your peers, you order few expensive, radiation-laden imaging studies, so go ahead and get that simple non-invasive, inexpensive and radiation-free ultrasound on this newly symptomatic patient.”  

Oops, day-dreaming again.  Sorry.

It turns out that this patient’s third-party payer, Anthem (Blue-Cross, Blue Shield), has a RQI, Radiology Quality Initiative.

Blue Cross and Blue Shield of Illinois has partnered with American Imaging Management (AIM)* to implement a Radiology Quality Initiative (RQI) program designed to meet the challenges of monitoring rapidly increasing utilization and managing rising high-tech imaging costs.

Who is AIM?  From the first line on their website: American Imaging Management, Inc. (AIM) is the intelligent solution for managing outpatient diagnostic imaging services. (Translation: Our business model centers on intrusion into the doctor-patient relationship, and in so doing, we will enhance your profits.)

And there is more.

The RQI program includes a prior authorization process promoting the utilization of relevant and cost-effective services by giving providers access to evidence-based guidelines that support ordering the most appropriate services for BCBSIL members.

Compliance with the RQI program is required.

For starters, as cardiologists go, I am pretty easy going, but the “provider” thing really irks me.  It shouldn’t.  Really, I should get past semantics, but it is a nasty boil.

Back to the point.

The point is: rationing of health care by erecting barriers. Placing obstacles in the way of getting simple diagnostic tests has become reality–for obvious reasons: profit motives of insurance companies, increased costs of diagnostic tests, and to be fair, occasional physician over-zealousness in ordering of tests.

We got the test done, but it was painful.
First, a medical assistant tells me, “Dr M, it’s Anthem, they are tough, we need another diagnosis, palpitations work for others, but not Anthem.”  Ok, she had chest pain with the palpitations. (She did.)  Minutes later, that’s not good enough either.  Now the case is passed to a second more seasoned scheduler of diagnostic tests.  Despite having inherited genes for a sunny disposition, she tells me in an exasperated tone, “this stinks, it is always the same; they make me tell the story to the first person, then put me on hold for a supervisor, forever, and then, I repeat the story again…After all that, they say, denied.  That is, until you consult with their doctor.” (the British one in a cubicle)
Sure, in this case, I may have got away without the simple ultrasound.  The arrhythmia was likely benign, the exam was normal, as was the twenty-five dollar ECG.  However, I like to treat patients as if they were family, or myself.  A risk-free, radiation-free echo to exclude an ASD, a cardiomyopathy or the like, seemed like a not-overkill-like request. But there are now barriers. We jumped over this time, but as increased demand for care intersects with human nature this will not be the case in the future.  And maybe that’s the goal.  Higher barriers means less consumption. 

It is not fair.  And I am frustrated.  Jumping this particular barrier took significant time, emotional energy and some inflammation.  Energy that would be better spent caring for others.

And I repeat: we will not have more healthcare, higher quality healthcare, and cheaper healthcare.  This equation is unsolvable.

In my dream world, it will be a fine day indeed, when patients ask their third-party payer how many providers-in-cubicles they will unleash on real doctors trying to do what is best for them.

You bet, I am aggravated.  I hang a lot on the doctoring peg.


5 replies on “Barriers…”

So my patient needs Fragmin rather than sit in the hospital for 3 more days.

Pre-approval required.

I spend 20 minutes on the phone.

The woman ends with "Were you satisfied with your service today?"

Yes. I was very happy to waste my time on the phone call. Why would you prescribe Fragmin for fun?

Silly question here: if the test is truly only $25 and I knew that, as the patient I'd pay it and not screw with the insurance company. But call me cynical, I'm doubting this. It may be $25 to the insurance company due to negotiated pricing but $100 to the patient who has not negotiated anything. Am I close on this?

I cant wait for O'bama care. Give me another shot of cool-aide.

Sherri – It ash been my experience that most doctors and facilities will accept the same payment amount from a patient that they would form an insurance company.

Would Anthem have put this policy in place if not for the overzealous doctors running un-needed tests?

Fragmin? Oh my. That is sad.

Sherri: An ECG costs 25 dollars. A stress echo much more, medicare allowable 269.

But our echo machine costs 300,000. and the technicians need to be paid–including their benefits. Herein is a microcosm as to why declining reimbursement is driving more specialists to be employed by hospitals.

A vignette: There exists a little hand held echo machines which I could put on a patient during an office visit. That would be cool, but unfortunately they are prohibitively expensive. Moreover, regulations dictate that to get paid, I would have to be certified, the lab certified, the technician certified, and a 3 page report generated for a 5 minute study. Excessive regulation and potential liability preclude much that could be accomplished in medicine.

Also, I just asked my billing department, and yes, we bill a self-pay the same as medicare allowable.

David: The problem is that a few poorly behaved children ruin it for the entire class. This is sad for the overwhelming majority who play by the rules.

Most experts believe that the real expansion in costs of medical imaging has less to do with doctor transgressions, and more to do with excessive regulation and inherent costs of doing business in our present system.

For example, how can an echo be cheap, if the machine costs 300,000. Doctors' over-zealousness gets the most press, but is the least contributory to the morass.

Thanks for writing.


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