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N=1, but I can confirm the experience of being disabled and getting medical care is mutually frustrating. Taylorism and one-size-fits-all fails hard. Appointm

N=1, but I can confirm the experience of being disabled and getting medical care is mutually frustrating. Taylorism and one-size-fits-all fails hard. Appointment times are standardized, despite patients not being standard. I know I'm going to take extra time. I have multiple chronic conditions, getting treatment is a mess. But I can't arbitrarily ask for more time during booking; it's all automated now. Worse, I need to confirm the doctor kept in mind _all_ of this in my treatment plan, because I've had awful reactions when they haven't. This is terrible for the doctor. I'm making them go over time, be late to the rest of their appointments for the day, and asking them for extra energy and brain cycles for treatment, for no extra money. And that's not even including accommodations I might need. I don't blame doctors for not wanting me in their practice. Controls put in place by administrators and insurance companies make me a pain in the ass to treat instead of a fun puzzle. Incentives make me more expensive, with lower payoff and higher risk. Which... is fucked.

Test0129 4y ago
> Worse, I need to confirm the doctor kept in mind _all_ of this in my treatment plan, because I've had awful reactions when they haven't. I'm not disabled but do have some chronic stuff. A couple decades ago I started carrying my medical record (well...the synopsis) to the doctors office for this reason. Especially when you end up in a clinic rather than a real private practice you're often not guaranteed to even see the same doctor twice. > This is terrible for the doctor. I'm making them go over time, be late to the rest of their appointments for the day, and asking them for extra energy and brain cycles for treatment, for no extra money. Though I'd not worry about this. My insurance EOB stated for a simple visit and bloodwork the doctor charged well over $1300. I saw the doctor for exactly 10 minutes. Make them work a little for their money.
- arkades 4y ago
  That’s not what the doc gets paid. That’s the pretend amount that the insurer and doc have agreed upon, before their agreed upon discount. Source: doctor.
  - User23 4y ago
    You as the doctor actually explicitly signed off on the real price? Not some administrator somewhere? Did you have any real input, or is your relationship to the insurer more like a driver’s relationship to Uber?
    - arkades 4y ago
      When working for a hospital, it’s an admin somewhere. When in private practice, the insurer generally has geographic monopoly, so I sign off on whatever they shove in my face if I intend to accept their patients. The only time I have a real say in price is in private practice for uninsured patients, which is where I set aside a piece of my time for charity care.
  - lotsofpulp 4y ago
    My EOBs have always stated what the healthcare provider is owed per the insurance price. It shows what was billed (the fantasy number), then the insurance price (or the discount), and patient responsibility (dependent upon an individual’s deductible/copay/oop max). Is that not true?
    - johannbok 4y ago
      That's right, only there is no normal physician visit that bills $1300. The absolute highest reimbursement you're gonna get for an outpatient visit - a level 5 evaluation and management first-time patient visit plus double-coding an 'prolonged visit for high complexity care' (some handful of insurers allow triple-coding a G2212) - (a 99205 + G2212 x 2) is 244.99 + something like $30 (I don't recall the G2212 reimbursement off the top of my head, but it's in that ballpark), for a total of about $275. +/- some adjustment for geography. That's not what patients pay - that's the total allowable reimbursement to the doc via medicare. I use medicare numbers here because almost all private insurers negotiate as %medicare. If I'm a hot specialty people are willing to pick an insurance plan over (say, cardiology) and there's a shortage of my folks in the area, I might negotiate up to something like 110-120% of medicare. Most of the time I'll be happy to get 105% medicare, and some folks will end up getting something like 95% of medicare. To hit $1300 there'd have to be: -A procedure, likely an inpatient or facility service, such as a small outpatient surgery, or an infusion. - Your doc has an in-house blood work lab and your insurer doesn't cover it, and the bill is actually a lab work bill That latter bit is a gray area - it's actually barred under the Stark Law, as clinical lab work is considered a Designated Health Service that's barred from self-referral, if it's a third-party lab that they own or co-own. If it's their own actual in-clinic lab, though, I'm unsure of how that works out (I don't run my own lab, so I just know of this second-hand). If you have a private-information-redacted copy of a 'normal' bill for $1300, I'd be happy to eyeball it - either to let you know something is off and worth appealing, or to learn something new for my self.
parkerhiggins 4y ago
Spot on. It becomes more clear when you ask who pays medical professionals salaries? Insurance companies do. Insurance companies are medical professionals’ bosses. The customer receiving treatment has no influence on the standard of care.
- lotsofpulp 4y ago
  Most customers could not afford the treatment at the standard of care they want anyway, hence the reason they purchase via insurance.
  - uoaei 4y ago
    A large portion of patients (customers seems like a dirty word in this context...) can't even afford insurance!
    - lotsofpulp 4y ago
      Of course, because the root problem in the US is most people cannot afford the healthcare that they expect to receive. Hence all the political maneuvering to redistribute wealth, and the corresponding efforts to avoid having one’s (present or future) wealth redistributed.
      - selectodude 4y ago
        That's half true - we've also made it difficult, if not illegal, for people to receive a lower standard of care. Anybody with a chronic condition needs to go see a doctor at least once a year in order to get the same prescriptions they've been on for decades. There are dozens, if not hundreds of conditions that could be handled by a pharmacy. I need an asthma inhaler every so often. I have to call a medical doctor in order to receive a prescription for an asthma inhaler. They're non-narcotic, I will always have asthma. But I need to bother a doctor for a medication that should be over the counter. It's silly.
  - User23 4y ago
eska 4y ago
* I'm making them go over time* Saying this as a non-disabled person, please don’t think of it/word it this way. It’s not you, it’s the disability, and you’re not responsible for it. If you take some time because of it I would gladly accommodate you as a service provider and show understanding as the next patient in line.
- iancmceachern 4y ago
  Me too, get yours, I'll gladly accomidate.
- threatofrain 4y ago
  If people prioritized their values this way then store owners would also fail to serve disabled people.
chromatin 4y ago
As a sibling commenter notes, it's great that you recognize the real root of this is often not a lack of empathy by physicians, but instead constraints of the system and especially the payors, who are not patients but insurers (or the federal government). Frankly, I'm surprised a small community-based primary care physician practice is even financially tractable in 2022. This bit from the article was also very interesting to me: Participants described both financial and time-related challenges of accommodating communication needs. One non-rural-practicing primary care physician stated: “I took it upon myself to actually hire an outside service to do [sign language interpretation]. They billed the office. …Their bill was higher than what we were making, so it was a losing venture. …It cost me $30 per visit for that patient, out of pocket.”
- lotsofpulp 4y ago
  > who are not patients but insurers (or the federal government). Or state government, in the case of Medicaid.
- abracadaniel 4y ago
  This issue is at least somewhat perceptual. If you have to charge everyone the same, but some patients cost more, then you raise the prices to account for the fluctuation and the other patients subsidize the more costly one. If, instead, the extra cost were covered by a tax rebate or something, then the cost is still subsidized to the other patients. Effectively, it isn't any different, it's just a matter of accounting. Making the disabled person pay extra for their services makes the flow of money more obvious, but at the expense of cruelty. I doubt many want to see that be the norm, but I think the result is then an argument of who sees the subsidy being paid on a bill. The doctor seeing a $30 loss on one patient and everyone pays $1 more, or 30 patients seeing a $1 interpreter fee.
  - brian-bk 4y ago
    You can't just "raise prices" in billing the insurance company though, and copays are often fixed by the insurance company..
pg_bot 4y ago
You might want to seek out a direct primary care clinic.
Dove 4y ago
Dude, you need direct primary care. When you pay the bills and no one else is involved, the doctor works for YOU. It's a profound difference, and one that it sounds like you need more than most. https://www.dpcare.org/ https://www.dpcare.org/ is a good place to start, but I guarantee there's direct primary in your city - just google for it.
- octokatt 4y ago
  This sounds good, but I have health insurance to cover for catastrophic health failure, which is very probable for me. I'd need to pay for both direct primary care and health insurance, and primary care payments wouldn't count towards my deductible. This is a situation without fast solutions.
  - Dove 4y ago
    I have, many times in my life, maintained direct primary care and insurance at the same time. The difference in the quality of care has been well worth the price for me, and your situation sounds worse than mine. It is not a requirement of medical care that it be effectively free. You can choose to pay for it! Direct primary is generally quite affordable and worth it, particularly if the regular system is not working for you. The services I have subscribed to over the last fifteen years have generally been in the neighborhood of $60/mo for an adult, and they tend to pay for themselves quite quickly -- once or twice a year, I have some sort of debilitating problem, and a doctor who knows me and cares about me resolves the issue in a matter of hours. Compared to waiting weeks for a non-solution, that's a bargain! Some people make up the fee just in the money they save on prescriptions. Seriously look into it.

Test0129 4y ago

> Worse, I need to confirm the doctor kept in mind _all_ of this in my treatment plan, because I've had awful reactions when they haven't. I'm not disabled but do have some chronic stuff. A couple decades ago I started carrying my medical record (well...the synopsis) to the doctors office for this reason. Especially when you end up in a clinic rather than a real private practice you're often not guaranteed to even see the same doctor twice. > This is terrible for the doctor. I'm making them go over time, be late to the rest of their appointments for the day, and asking them for extra energy and brain cycles for treatment, for no extra money. Though I'd not worry about this. My insurance EOB stated for a simple visit and bloodwork the doctor charged well over $1300. I saw the doctor for exactly 10 minutes. Make them work a little for their money.

arkades 4y ago
That’s not what the doc gets paid. That’s the pretend amount that the insurer and doc have agreed upon, before their agreed upon discount. Source: doctor.
- User23 4y ago
  You as the doctor actually explicitly signed off on the real price? Not some administrator somewhere? Did you have any real input, or is your relationship to the insurer more like a driver’s relationship to Uber?
  - arkades 4y ago
    When working for a hospital, it’s an admin somewhere. When in private practice, the insurer generally has geographic monopoly, so I sign off on whatever they shove in my face if I intend to accept their patients. The only time I have a real say in price is in private practice for uninsured patients, which is where I set aside a piece of my time for charity care.
- lotsofpulp 4y ago
  My EOBs have always stated what the healthcare provider is owed per the insurance price. It shows what was billed (the fantasy number), then the insurance price (or the discount), and patient responsibility (dependent upon an individual’s deductible/copay/oop max). Is that not true?
  - johannbok 4y ago
    That's right, only there is no normal physician visit that bills $1300. The absolute highest reimbursement you're gonna get for an outpatient visit - a level 5 evaluation and management first-time patient visit plus double-coding an 'prolonged visit for high complexity care' (some handful of insurers allow triple-coding a G2212) - (a 99205 + G2212 x 2) is 244.99 + something like $30 (I don't recall the G2212 reimbursement off the top of my head, but it's in that ballpark), for a total of about $275. +/- some adjustment for geography. That's not what patients pay - that's the total allowable reimbursement to the doc via medicare. I use medicare numbers here because almost all private insurers negotiate as %medicare. If I'm a hot specialty people are willing to pick an insurance plan over (say, cardiology) and there's a shortage of my folks in the area, I might negotiate up to something like 110-120% of medicare. Most of the time I'll be happy to get 105% medicare, and some folks will end up getting something like 95% of medicare. To hit $1300 there'd have to be: -A procedure, likely an inpatient or facility service, such as a small outpatient surgery, or an infusion. - Your doc has an in-house blood work lab and your insurer doesn't cover it, and the bill is actually a lab work bill That latter bit is a gray area - it's actually barred under the Stark Law, as clinical lab work is considered a Designated Health Service that's barred from self-referral, if it's a third-party lab that they own or co-own. If it's their own actual in-clinic lab, though, I'm unsure of how that works out (I don't run my own lab, so I just know of this second-hand). If you have a private-information-redacted copy of a 'normal' bill for $1300, I'd be happy to eyeball it - either to let you know something is off and worth appealing, or to learn something new for my self.

parkerhiggins 4y ago

Spot on. It becomes more clear when you ask who pays medical professionals salaries? Insurance companies do. Insurance companies are medical professionals’ bosses. The customer receiving treatment has no influence on the standard of care.

lotsofpulp 4y ago
Most customers could not afford the treatment at the standard of care they want anyway, hence the reason they purchase via insurance.
- uoaei 4y ago
  A large portion of patients (customers seems like a dirty word in this context...) can't even afford insurance!
  - lotsofpulp 4y ago
    Of course, because the root problem in the US is most people cannot afford the healthcare that they expect to receive. Hence all the political maneuvering to redistribute wealth, and the corresponding efforts to avoid having one’s (present or future) wealth redistributed.
    - selectodude 4y ago
      That's half true - we've also made it difficult, if not illegal, for people to receive a lower standard of care. Anybody with a chronic condition needs to go see a doctor at least once a year in order to get the same prescriptions they've been on for decades. There are dozens, if not hundreds of conditions that could be handled by a pharmacy. I need an asthma inhaler every so often. I have to call a medical doctor in order to receive a prescription for an asthma inhaler. They're non-narcotic, I will always have asthma. But I need to bother a doctor for a medication that should be over the counter. It's silly.
- User23 4y ago

eska 4y ago

* I'm making them go over time* Saying this as a non-disabled person, please don’t think of it/word it this way. It’s not you, it’s the disability, and you’re not responsible for it. If you take some time because of it I would gladly accommodate you as a service provider and show understanding as the next patient in line.

iancmceachern 4y ago
Me too, get yours, I'll gladly accomidate.
threatofrain 4y ago
If people prioritized their values this way then store owners would also fail to serve disabled people.

chromatin 4y ago

As a sibling commenter notes, it's great that you recognize the real root of this is often not a lack of empathy by physicians, but instead constraints of the system and especially the payors, who are not patients but insurers (or the federal government). Frankly, I'm surprised a small community-based primary care physician practice is even financially tractable in 2022. This bit from the article was also very interesting to me: Participants described both financial and time-related challenges of accommodating communication needs. One non-rural-practicing primary care physician stated: “I took it upon myself to actually hire an outside service to do [sign language interpretation]. They billed the office. …Their bill was higher than what we were making, so it was a losing venture. …It cost me $30 per visit for that patient, out of pocket.”

lotsofpulp 4y ago
> who are not patients but insurers (or the federal government). Or state government, in the case of Medicaid.
abracadaniel 4y ago
This issue is at least somewhat perceptual. If you have to charge everyone the same, but some patients cost more, then you raise the prices to account for the fluctuation and the other patients subsidize the more costly one. If, instead, the extra cost were covered by a tax rebate or something, then the cost is still subsidized to the other patients. Effectively, it isn't any different, it's just a matter of accounting. Making the disabled person pay extra for their services makes the flow of money more obvious, but at the expense of cruelty. I doubt many want to see that be the norm, but I think the result is then an argument of who sees the subsidy being paid on a bill. The doctor seeing a $30 loss on one patient and everyone pays $1 more, or 30 patients seeing a $1 interpreter fee.
- brian-bk 4y ago
  You can't just "raise prices" in billing the insurance company though, and copays are often fixed by the insurance company..

pg_bot 4y ago

You might want to seek out a direct primary care clinic.

Dove 4y ago

Dude, you need direct primary care. When you pay the bills and no one else is involved, the doctor works for YOU. It's a profound difference, and one that it sounds like you need more than most. https://www.dpcare.org/ https://www.dpcare.org/ is a good place to start, but I guarantee there's direct primary in your city - just google for it.

octokatt 4y ago
This sounds good, but I have health insurance to cover for catastrophic health failure, which is very probable for me. I'd need to pay for both direct primary care and health insurance, and primary care payments wouldn't count towards my deductible. This is a situation without fast solutions.
- Dove 4y ago
  I have, many times in my life, maintained direct primary care and insurance at the same time. The difference in the quality of care has been well worth the price for me, and your situation sounds worse than mine. It is not a requirement of medical care that it be effectively free. You can choose to pay for it! Direct primary is generally quite affordable and worth it, particularly if the regular system is not working for you. The services I have subscribed to over the last fifteen years have generally been in the neighborhood of $60/mo for an adult, and they tend to pay for themselves quite quickly -- once or twice a year, I have some sort of debilitating problem, and a doctor who knows me and cares about me resolves the issue in a matter of hours. Compared to waiting weeks for a non-solution, that's a bargain! Some people make up the fee just in the money they save on prescriptions. Seriously look into it.