The Over Under

This posting will analyze the "over" questions that are rarely asked or answered.  I imagine many of my fellow DPC physicians have made some of these observations as well, and we need to find a way to share these observations in a tactful way with our patients and each other. Read on to determine if you might be over-insured, over-doctored, over-lawyered, or just overwhelmed.

Are you over-insured?  We are used to asking this question of ourselves when it comes to car, home, life, or disability insurance.  As physicians we rarely can rely on our own expertise for an answer here, and instead we often use independent insurance brokers, and this is usually a wise decision. When it comes to health care our individual patients have great difficulty answering this question, and rarely are these same patients in a position to seek wise advice from an independent broker (assuming one can be found) since their health insurance plans are often selected by an employer or government entity.  As DPC physicians we know the truth:  patients that are on low deductible plans are usually overinsured, and some of the patients on the highest deductible plans might be underinsured.  We need to do a better job of pointing out valuable options for our patients that pair nicely with DPC.

What if you (as a physician) were able to purchase customized health insurance?  Consider this breakdown of costs by condition from Kaiser Family Foundation.  The top nine spending areas in order are 1) cardiovascular disease, 2) orthopedics, 3) COPD, 4) Diabetes, 5) neurologic disorders, 6) cancer, 7) emergent trauma, 8) urologic disorders, and 9) digestive disorders. Given a choice from this list I would likely purchase insurance that would cover neurologic disorders, cancer, emergent trauma, and digestive disorders.  Purchasing insurance only for these four areas would be a fraction of the cost of a full plan, and these are the areas that I would anticipate could be the most costly and devastating to me.  Most patients assume they need to buy everything, but consider these two common examples:

Orthopedics - Most patients don't stop to consider that the majority of orthopedic operations (especially knee and shoulder surgeries) are elective in nature.  The patient is deciding to pursue the surgery to reduce pain, and may or may not have attempted injections, weight loss, activity modification, physical therapy, etc.  We should stop paying for these elective procedures with insurance, and the price will drop through the floor (just like at the Surgery Center of Oklahoma), thus increasing patient access to these procedures that are routinely delayed and rationed by third party payors.

Cardiology - It has been well documented that a large portion of cardiac stents (while they do relieve chest pain) do not affect all cause mortality.  I'm not advocating that we should stop stenting patients or sending them to cardiologists, but we should make our patients aware of the hidden limitations of modern medicine.

Are your patients over-doctored?  The majority of patients with chronic conditions are over-doctored, especially Medicare patients.  These patients are referred from one physician to another and may have five or more cooks in the kitchen when one or two would do just fine. Most of the cost is born by the government, so the patient doesn't complain too much, and the lack of a primary care physician willing to take the time to make sense of the madness and end the never ending cycle of specialty follow ups is overlooked.  As DPC physicians we get to hold specialists accountable for rendering an efficient and cost effective opinion, and then we usually manage the patients ongoing condition after obtaining a specialty opinion.  Our DPC patients return to our practice to see what WE think of the consultant's recommendations before going through with ten new labs and an MRI.  WE hold the specialist accountable by demanding a coherent assessment and plan rather than ten pages of EMR nonsense.  Take a look at this data on specialty referrals Family Physicians' Referral Decisions (Results from the ASPN Referral Study), Journal of Family Practice, March 2002, Vol 51, No 3, 215-222.  It might help you differentiate yourself from traditional practices that tend to over-doctor patients.

Are you over-lawyered?  Physicians forget to ask themselves this question, but I see it happen often (almost as often as being over-doctored).  Have you made any effort to do your own homework prior to consulting an attorney?  You need to know enough to know that you are asking the right questions because the attorney might just go ahead and answer your questions - even if your questions are the wrong (and expensive) kinds of questions.

Imagine a 40 year old male patient with a high, deductible plan walks into the office of a family physician in the traditional system and requests his vitamin D level be drawn along with a battery of rheumatologic tests due to the new onset joint pain in his knees.  The traditional physician that has ten minutes to spend with this patient is likely to just order the tests without thinking twice, and then the patient gets tagged with a big bill.  The DPC physician is likely to spend thirty minutes with the patient determining a clinical source for his knee pain and likely educating him about why these additional studies are not necessary at this time.

Your attorney needs to have the intelligence and the integrity to tell you when you are requesting an expensive and unnecessary service.  DPC is a new and rapidly developing area of the law, so you cannot assume that any "health lawyer" will know enough about the subject. Please use the free resources on this website to gain an understanding of the issues so that you don't walk into a law firm's office begging to be over-lawyered - because they just might grant your request.