The System Goes Flat

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.

7 thoughts on “The System Goes Flat”

  1. Funny, I have discussed this topic with my auto-tech guy friend and a Hospitalist. Separately, and not with the intent of drawing parellels like you did. Greg, the Hospitalist, has shared that people come in to the emergency room with symptom A, but they somehow expect the doctor to be doing a whole body check and to diagnose all of the ailments they’ve been ignoring for months. As he says, the doctor is there to look at symptom A, if anything else is caught it is because that body part needed to be included in the exam. In other words, people have the expectation that the doctor will be doing a full checkup, even if the person is there for a cut on their leg. That’s a dangerous expectation, I think. He and I did not discuss profit implications, just health implications of that kind of thinking. He said, what people really want to hear is “You are healthy” or “You have X wrong, here’s the fix”, that they need that reassurance in addition to what they actually came in for.
    My auto tech guy friend is very honest, doesn’t scheme or trick people. He’s plenty busy with work, no need to fake problems for more. But he freely admits that they expect to find extra problems in someone’s car and that is why they do a thorough check. They essentially “count” on that as part of their profit margin. He won’t make up problems, but, sure, he’s happy to find that you need new tires when you come in for an oil change. Symptom A gets you through his door, and he makes money when he finds X, Y, and Z are also bad. Quite frankly, I think most people take such poor care of their cars that it’s not difficult for him to see the neglected and ailing parts of cars. I, as a consumer also don’t mind when he finds extra problems in my car. I expect them to do a thorough check on my car. Of course, I trust him with my life AND my car, so anything extra he finds I completely trust in. And he’ll tell me what can wait to be fixed and what can’t. This isn’t going to be true of a random auto tech that I meet for the first time when bringing my car in to a new shop. The random auto tech may or may not be honest. OR the opposite – too busy or lazy to do a thorough check of my car.

    What is the solution to both your dilemma, Greg the Hospitalist’s dilemma, and our dilemma with auto techs?

    It’s very simple, really. You know the answer. Relationships. Yep. Building relationships builds trust. Keeping the same doctor, the same auto tech, the same hairstylist. You don’t have to date your auto tech like I do (haha) to build a relationship with him. Time builds a relationship. Time allows conversations and allows you to get a feel for someone’s ethics. With all 3 of those, time also allows you to see the fruits of their labor. If your doctor keeps you healthy or at least less ill, if your car runs smoothly, if your hair cut is good…then you build trust in their judgement and character. If your doctor is rude or blows off your concerns, if your auto tech tells you to buy new tires every 500 miles, if your hair looks awful…well, pretty soon you’ll figure out that it is not a trustworthy relationship.

    Again, Key word. RELATIONSHIP. Build relationships and people care about the outcome. People want to take good care of each other. Derek goes to Doctor for his gout, Doctor brings his car to Derek for oil change. Symbiosis. Trust. A good working relationship. And if the doctor tells derek he needs an x-ray b/c his lungs sound bad, Derek knows he can trust him. Just like the Doctor believes Derek when he says he needs a new air filter in his car.

  2. Oops I forgot that I started with Greg the Hospitalist. The solution to his dilemma is still in Relationships. I think people who have a good relationship with their doctor will feel comfortable coming to see him/her for a checkup on a more regular basis. And will feel more comfortable being honest about what ails them, rather than waiting til something else happens to them that drives them to the emergency room. Plus, the regular doctor will, over time, be familar with the person’s health problems and will be more likely to pick up on signs that something is going wrong. When I see my doctor, she starts sometimes with “How are you doing?” I share how things have been going since I last saw her and that gives her a good starting place. She is able to compare my current emotional and physical health to the last time I saw her. I feel heard. I feel respected. I feel like I’m getting good trusted care. I think this is a far better way to have health monitored than seeing an ER doc and hoping him/her picks up on my high cholesterol while I’m there to get stitches in my knee. LOL (I’m exaggerating but still…). Just no substitute for a good working relationship with your doctor, or other people that provide services.

  3. I’m glad you weren’t injured; a simple flat is safer than a blowout. As for getting ripped off by the car repair place, it happens more than people realize. My brother went to auto mechanic school for a year. He switched career tracks after that because part of the curriculum included tips on how sell people “repairs” that weren’t needed. He couldn’t see spending his life cheating people just to make a buck. People just have to hope that they find an honest mechanic.
    It’s very hard, if not impossible, for patients to know if what is being done is actually necessary.
    Too true. That’s one thing that’s nice about the internet. Once patients have a diagnosis, it’s pretty easy to find out how their particular ailment is usually treated. Learning, repeatedly, that what my doctor has done is exactly what’s recommended, increases my confidence in my doctor. Because I really don’t have any more way of knowing how competent/honest he is than you have in knowing those things about your mechanic.

  4. One big difference for most people with a visit to the doctor vs. the auto mechanic is insurance. Withhealth insurance there’s really impetus to limit the care you receive since you don’t pay for it (directly anyway). So when the internist orders the $1000 MRI just to “be sure” your headaches aren’t a brain tumor, what do you care, insurance is covering it. If your mechanic tells you that you need a $1000 job that you have to pony up the cash on the spot you’ll be a little more leary….

  5. That’s not always true. Insurance companies have, unfortunately, gotten into the business of deciding what care is, and is not, needed. I’ve been told that insurance will cover the eye surgery to fix my strabismus, because there’s a certain argument it’s “medically necessary”, but insurance will not cover Lasik for nearsightedness because that’s “cosmetic”. The insurance industry is also why doctors have gotten into the CYA game of ordering every test under the sun, even when they themselves don’t think all the tests are necessary, because the docs are tired of bureaucrats breathing down their neck and second-guessing their decisions. “Why did you only order Test N? Why didn’t you order Tests A-M first?” Docs get tired of explaining that *in their medical judgment* Tests A-M weren’t necessary, but Test N fit their patient’s needs perfectly. We *all* end up footing the bill eventually for Tests A-M, in higher doctor’s fees (malpractice premiums) and higher insurance costs (the insurance companies still have to make a profit, right?).

  6. -well put,Kaylie1-as a retired mechanic, who got into the trade after graduating from university, due to getting ripped off by garages, the best protocol is to go by the scheduled maintenance that’s found in your owner’s manual
    & with these high tech cars, Always insist on OEM parts [Original Equipment Manufactured] –> just an infinitestimal variation in tolerances/settings/calibrations can set off a cascade of computers [cars have 10 or more]& modules [20+] causing all sorts of driveability issues.
    [if Y’all think getting a car fixed is a PITA, just multiply times ten& that’s what it’s like for the poor mechanic, who has to diagnose the car. Yes, there is a machine that does that, but, just as in medicine, you have to read between the lines
    All the stuff a mechanic learns is Obsolete in 5 years, due to ‘technological advances…
    -the mechanic who’s invested $30+k in tools& faces trauma in the form of cuts, bruises, burns, amputation etc EVERY day,every minute
    Being a mechanic is like being a motorcyclist: not a question if you get hurt, but when.
    Truly, a mechanic’s lot is not a happy one.
    2- get your chariot oil undercoated.
    Your car has 20 or so grounds,compared to 3 or so for 80’s cars. Any one of those grounds that gets corroded will cause a cascade… Plus everything will be unseized,rusted, so that you won’t be charged extra for using ‘teddy the torch’
    3- use common sense. worn tires,brake rotors&pads are easy to spot:
    just ask the service guy to show you what the new ones look like
    [it doesn’t matter if they’re for a different car, cuz only the sizes differ- you’re looking for Thickness of brake material in the pads & rotors that are smooth& shiney with no grooves in them. Same goes for belts.]
    HTH cheers

  7. I live in Canada, where we’ve had Medicare (free health care) for just over 50 years. You describe the problems you see with doctors prescribing unnecessary tests; it is the opposite here. Here, the norm is the bare minimum. Doctors will do as much as they can without asking for a test, and when they do, it’s just the one. Not multiple tests. (Excluding the most severe cases, of course) Almost all surgical procedures are backed up anywhere from 4 months to 2 years. My grandfather had an aneurism for years before doctors finally decided it was too risky to leave. Once they made the decision to operate, the surgery was scheduled for a date 6 months later, but was postponed multiple times because a member of the surgical team couldn’t make it. His original appointment was in February; they operated at the end of December.
    I guess what I mean to say is, if you have a host of different tests and procedures to choose from, with the expectation that you can rely on their availability, count your blessings. The system could be a lot worse.

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