Tuesday, October 28, 2003

Passing the buck

One of the things I have disliked about working at Kaiser is that many patients just have no regard for the cost of health care. Because it is a prepaid health plan, most of the time they only pay a $10 or $20 copay, or none at all.

At least once a week, somebody comes in with a sore shoulder or knee and says, "I think I need an MRI." And several times a day, someone asks about Nexium or Celebrex or whatever the latest prescription medication commercial is pushing. A little old lady with no problems walking asked me to order her a motorized scooter, just like her neighbor, because "Medicare will pay for it". Can you imagine what would happen if full body CT's became covered? Yikes!

Part of my role at Kaiser is to be a guardian of our members' health care dollars. I know full well that higher utilization of high costs drugs and tests will only mean higher copays and premiums to the patients. But some patients feel like they are owed the world because they (or their employer) pays for their health care premiums. And no, I don't get paid more for restricting health care spending. At Kaiser, we physicians are paid the same regardless of how many tests I order or how many prescriptions I write.

This recent entry on MedRants refers to an article that discusses how patients will overutilize health care if they don't have to pay for it. Of course. It's only human nature. It is certainly something I've seen firsthand.

Case in point: When Viagra first came out, men would make appointments for physicals, back pain, athlete's foot, and right at the very end, casually mention that there was one other problem they wanted to discuss. And I'd have to evaluate whether they had a "medically necessary" condition justifying Viagra, or if they didn't, in which case they'd have to pay for Viagra on their own.

Many men clearly had erectile dysfunction. But some just wanted to try Viagra because they heard that it made sex "better". One guy asking for Viagra was married, but his wife was living overseas. And he hadn't seen her for the past 5 years. Turns out he had a mistress in the States! What should I do with that???

It just didn't seem right to me that Kaiser member dollars were being spent for a condition which wasn't clearly "medically necessary". And I resented being made the sheriff in charge of who should get treatment and who shouldn't.

A few years later, Kaiser revised the terms of its coverage and now covers treatments for sexual dysfunction as a separate category, paying 50% of the cost, rather than 100%. Now when patients ask for Viagra, I just prescribe it for them. Maybe it's because Viagra's been out for a while, or maybe it's because of the increased cost-sharing, but I don't get too many requests for Viagra anymore.

I realize this is not the current trend in health care coverage. We currently have two ongoing strikes in Southern California, one by the grocery workers, the other by the bus mechanics, both over the issue of health care costs. The employers want to pass more of the cost to the workers; the union wants the employer to pay for all of the workers' health care.

As a physician entering a fee-for-service world, I look forward to having patients bear more of the costs of their health care as a way to maintain checks and balances, to reduce the spiraling cost of health care. Those who want an MRI for that shoulder pain can still get it if they really want to pay for it. And those who really need it will find their money well spent. But I'm aware that there will also be situations that I didn't encounter at Kaiser, like when someone can't get necessary treatment because they can't afford it.

And what am I going to do when patients can't afford to see ME? Hmmm.....still thinking.....

Countdown: 69 days until target start date