Y\’all Come Back Now, Ya Hear?

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.

9 thoughts on “Y\’all Come Back Now, Ya Hear?”

  1. Wow, I never saw the follow up comments. This was definitely someone unfamiliar with you, for sure.

    I think you brought up an excellent point; you are the one taking the risk when you write the script. Any patient receiving medication must be monitored. If their condition is such that a prescription is necessary, they need adequate follow up care. It is for their own good. It is necessary.

    It seems patient education is needed, to clarify the roles and responsibilities of each party. Often times, I feel patients must not understand what it is that their physician may be monitoring, and how important it is to be routinely followed. If they understood this, I can't imagine they would entertain the thought that paying for this care is an unreasonable inconvenience.

  2. I also would like to add, that I do understand the cost factor for many of us today. Costs have sky rocketed and they aren't about to get better at this point. Many will face higher rates now in order to cover the cost for others; it's all the more important for patients to understand why they need to be seen.

    I won't get into the political issues. I loathe politics; I just wanted to state that I also understand why people put off their medical care. I understand what it is to have to decide between food and medication, etc.. But, this is also why I feel, educating them about the need for follow up care is so important .

    If they don't take care of their high blood pressure, for example, they may one day face even more expense. Sometimes, catastrophic costs will result. Sometimes, permanent loss of income from an event that could have been preventable, had they been under a physician's watchful eye and care.

    Sorry so long, Rob. You know I usually don't comment this much. It's just that I feel for both sides of the coin, so to speak.

  3. I agree. This post was actually me musing on the other side of the coin. When is bringing people back an excessive thing?

  4. Within our own comfort levels, we physicians should try to be reasonably accomodating when it comes to issues such as follow-up frequency or whether someone needs to come in to have a particular problem addressed.

    However, one thing we should keep in mind as well is that those patients most likely to devalue their doctors and complain about having to come in are, in my opinion, the ones most likely to cry foul and blame their doctors when there is a bad outcome (and their doctors did not require them to be seen).

  5. Alice Robertson

    How do internet physicians get off with prescribing drugs w/o seeing the patient? I know many are overseas, or to the south, but I know someone who ordered and received the drugs from another state via the internet. It was expensive, but sorta bizarre that they could get some pretty heavy-drugs as easy as they did. If we head into the era of e-patients one wonders about ease v real time patient care.

  6. Alice, I don't know if you meant to address me or add a comment to Rob's post. I don't know of any internet physicians that would do such a thing. I know there are unscrupulous sites out there, but no reputable physician I know would do this. I am not a physician.

    I agree with you. This practice you speak of is dangerous. Even with technological advancements in our society, it will never take the place of physicians needing to do a thorough physical exam. I think Rob can better address this.

  7. Dr. Rob, If every doctor took the time to reflect like this, patients wouldn't question the value of a follow-up visit. I applaud you for posing the question. I remember my doc telling me to schedule a follow-up visit after surgery to remove a cyst on my big toe — only if I had pain, redness, oozing or questions. I really appreciated that he considered my time and money in the equation.

  8. Hi! It was an open question. I have six children, homeschool, have a parent with Alzheimers who visits daily (and asks the exact question about 20 times each day, so by the evening I am chasing imaginary flies). With four of my children being daughters……….let me say…………you really can't put much credibility in much of what I post! <G> The non-stop chatter here means what little I have left of my brain is split while typing.

    Part of the reason I posted is because it would seem some doctors are willing to venture into a type of e-patient care. I can understand the webcam aspect (a step up from WebMD), but because I am pretty ignorant about some of this stuff one wonders how vitals will be accurate (I am sure some cyber-genius will figure out a way to capitalize on this). I tend to think patients would enjoy this more than doctors (my mind dances with scenarios of an overwhelmed mom holding a sick baby while trying to do a type of web conference with the other kids fighting in the background, or having a food fight [knowing that kids love to bicker when mom is on the phone]). Basically, a doctor's waiting room personified! <G> I think it would be useful, but limited.

    I read this week that doctors will have to change their identity and understand that with today's cyber-patients being much better informed (and much more ill-informed, which is relative…. whether that's better than old wives tales), they have to learn how to be translators for the patient. What a task! To try to keep up on all the information patients will drag in from cyberspace on so many different subjects and levels. We may need the specialists to specialize on even more minute details just to keep up with the vast volumes of information being posted in the realms of nutcase medicine to true medicine…….hmmm…….another relative term?

    Blah, blah, blah! Ha! I type fast, and listening to questions from my kids, so I better sign-off.
    God bless, Alice

  9. I appreciate that you're doing what's in the best interests of your patient's health.

    Consider, though, that when you have 19 copays in one year, it adds up regardless of how low the copay is. With that money, I could have bought new winter coats for all my kids. New shoes, too – plus a few other necessities.

    Sometimes patients are just tired of being patients. It gets frustrating to have it be a full-time job keeping track of medical appointments. If a non-routine issue needs to be addressed it will be postponed as long as possible because you just know it'll be a snowball appointment…

    Some of us do understand that doctors need to see patients if they're writing prescriptions, but when I saw my PCP three times last month, it sure would have be nice if next month's follow-up (which was scheduled last December) could've been addressed at that last appointment instead of making me go in once again. It sure would be nice to combine some of those appointments and tack the routine follow-up onto the end of another office visit!

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