Being an Informed Patient
Question: In today’s medical environment, how can a patient be sure that a doctor or a hospital is not recommending an X-ray or a test simply to protect themselves, or to bulk up the billing? How can a patient ensure that the recommended tests and procedures are truly needed? Similarly, when facing complicated illnesses, how can a patient make good choices about expensive, invasive, and sometimes risky procedures and testing that are recommended to them?
In an era of competitive insurance plans and premiums, patients have various options of what plan to choose for their families. Healthcare reform has recently brought opportunities for coverage for people who previously could not find coverage, e.g., preexisting conditions, students able to continue to have coverage until age 26 years on their parents’ plans, no charge for once-a-year annual physical (AP), and options for the health savings account (HSA).
There is no need to question the AP with preventive coverage: the office visit itself, the annual blood test, mammogram, 10-year colonoscopy, annual pap smear, and prostate test (PSA). There is enough data that AP and preventive health care does allow for early detection of disease and opportunities of cure, and decreased morbidity and mortality.
For other situations, one can go on WebMD.com even before going to the doctor to get an idea of what to expect. Tests and procedures for certain conditions and situations are clear cut, published and managed by protocol; there will be no difference in opinion from institution to institution or physician to physician, provided similar drugs and technology are available. (This would not be the case, for example, in developing countries where expertise and certain treatments may not be available. In that situation, perhaps one is at the mercy of whatever there is available at that point in time.) If there is any suspicion that a physician is suggesting a test that seems out of line, get a second opinion. Even in academic institutions there can be differences in the management styles of problems.
Certain factors help assure patients that they are not getting unneeded procedures: Insurance companies’ mission is legally to not pay claims, to collect premiums, to bill penalties, to raise premiums as needed to bulk their bottom line with the physician and hospitals holding the bag. Furthermore, insurance companies, Medicare, Medicaid, and technology companies have lobbied to make electronic medical records (EMR) mandatory for the healthcare industry, one theory being that it will allow them to control fraud. Services in health care are paid by a complex slew of codes, both ICD (from the World Health Organization) and CPT (from the American Medical Association). Even a $10 bill will only be paid when accompanied by matching double sets of codes. This drastically curbs opportunities for bulking up a bill. When used as intended, EMR can help avoid duplication and help with diagnosis and treatment. Critics suggest that because there is not enough federal oversight now, EMR can also make it easy to add charges fraudulently. [See the reference cited at end of this article.] It is helpful to have someone with you in the hospital to help you record procedures done as well as instructions given.
When doctor-shopping or hospital-shopping, check Healthgrades.com (one of Time magazine’s 50 best websites of 2011), look at websites, patient reviews online, and even the state licensing board.
Although patients may not want to spend money, tests may be needed. I myself experienced recently a patient who asked me to prescribe her an osteoporosis medicine because her mother was on one at her age and her younger sister was already on one. She did not want a DEXA scan to first actually give me an opportunity to see if she had the condition and if she would give me a marker to compare and monitor treatment with time. She accused me of making money at the cost of her illness. She was upset that she would need a DEXA and have to pay for it since her plan prescribed the test under her annual deductible. Within minutes she had smeared me on social network accusing me of making money. Although I had encouraged her to seek a second opinion, she chose to instead write me up to her insurance carrier.
There are many examples of patients suspecting doctors and hospitals of bulking their bottom line. However, the human body is intricate; doctors cannot be expected to treat by intuition but rather in concert with test reports and data.
[Gulshan Harjee, M.D., is a board certified internist in private practice with an emphasis on prevention. Please email your health and medical questions for consideration in this column to: gharjee@comcast.net. The material in this column is of a general nature, and must not be construed as specific medical advice. This column rotates monthly along with the Fitness Lifestyle column by Aarti Patel.]
Website Bonus Feature added and article updated on October 2, 2012
Link:
"Medicare Bills Rise as Records Turn Electronic"
By Reed Abelson, Julie Creswell, and Griff Palmer.
The New York Times, September 21, 2012.
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