The Patient Comes Last?

In the service industry, which as physicians we certainly are a part of, a popular saying is that the customer always comes first. The implication is that in order to thrive in an industry, you have to cater to the customers/patients as it is they who will ultimately decide where they take their business.

In medical school, the emphasis was on prioritizing the patient (the Hippocratic Oath that every graduating medical student recites is indicative of that fact). But sadly, in modern practice, phrases like “the patient comes first” are little more than lip service. 

How can the noble profession of medicine — whose entire mission is saving and improving patients' lives — not put patients first?

It’s hard to pinpoint when the physician-patient model got warped, but I would venture a guess that it occurred shortly after priorities shifted from the patient to the financial bottom line. I can't speak for every specialty, but I can certainly shed some light on what is going on in radiology (spoiler alert: patient care is a low priority). Medical insurance companies charge premiums for their customers and hope that the amount exceeds the medical services they end up covering so that they can pocket the profit. And, this might be surprising, coming from a radiologist whose livelihood can depend on ordering imaging, but I am not against efforts to curb expenditures on advanced modalities (such as CT and MRI), which are the priciest types of equipment to play with. I understand the medical insurance companies’ business model, and I get where they are coming from. After all, the pioneers of medicine, including the renowned Sir William Osler, practiced great medicine well before the first patient ever underwent a CT scan. Dr. Osler relied on clinical skills alone to diagnose. (One famous example of a remarkable diagnosis was when Osler correctly diagnosed a patient as having aortic insufficiency just by feeling the patient's toe, thus highlighting the importance of the "water-hammer" pulse sign.) That said, ordering a CT should not be a knee-jerk reaction for every presenting symptom. Alas, in Cover Your Ass medicine, the fear of litigation attached to missing something weighs heavily on every practicing physician's mind.

There are some insurance protocols, however, that I do find quite objectionable. Unless you are very lucky, you have, at some time or another, been a patient in the medical system. You know that it’s an inconvenience to go to the doctor's office to get a check-up or have a problem looked at. Our schedules are busy, physicians or not, and medical appointments often involve taking time off from work, and sometimes, time to travel to the facility. It is therefore quite reasonable to wish that every study/test ordered could be done in one visit for convenience's sake. But patient satisfaction/convenience apparently has no bearing on the standard insurance protocols in place. I am sure there are countless examples of what I’m talking about, but I will just list a few to drive home the point:

Some “genius” in the medical insurance industry decided that if two tests are ordered, and both concern the same area of human anatomy — even if they are completely different tests that test two completely different things — only one test can be performed (and more importantly, reimbursed) for a particular patient visit. Your patient has thyroid nodules that need imaging evaluation and you are worried about atherosclerotic disease in the carotid arteries? Tough luck. If you (appropriately) order a thyroid ultrasound and a carotid ultrasound, the insurance company will only pay for one because the thyroid ultrasound concerns the same anatomic region (the neck) as the carotid ultrasound. So, to avoid having to pay exorbitant out-of-pocket costs, the patient ends up having to come on a separate day to have the second test performed — which makes the radiology department look like the bad guy.

The exact same scenario unfolds if you are worried about a patient having DVT and atherosclerotic disease (requiring an arterial study). Both of these studies are labor-intensive and look at different structures, despite being in close proximity to each other (i.e., both are in the leg). But this argument falls on deaf ears over at the insurance company, which will still, even after you try to explain the prudency of ordering both studies, not allow both to be performed on the same date. Again, highly inconvenient and further proof that the patient comes last.

Unfortunately, insurance reimbursement policies also affect the physician. It is logical to assume that if something takes longer and requires more detailed work/analysis, then it should be reimbursed at a higher rate. Alas, this is not the case.

Take MRI, for instance. A routine head MRI can take around 30 minutes to scan. If a clinician wants a more detailed analysis of a particular structure, say the trigeminal nerves, additional imaging sequences can almost double the time. This more detailed study also generates significantly more images for the radiologist to review. You would, therefore, think the study including the trigeminal nerves would receive a higher reimbursement to compensate for the extra physician time and labor. You would be wrong. Thanks to how medical coding has devolved, both studies are now coded, and thus reimbursed, the same.

It is akin to having a landscape company charge you the same fee for mowing your lawn as for mowing your lawn and trimming the trees and bushes, and doing the edging, and cleaning out the gutters, and etc. It wouldn't fly in the landscaping industry, yet we are forced to accept it in ours.

It would certainly be nice to go back to the days when the doctor-patient relationship actually meant something. But with insurance companies interloping as middlemen,  that period of medicine appears to be gone.

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