Readers weigh in on bedside skills, health care costs

Back to the bedside

I would like to applaud Jack Ende, MD, MACP, for recent comments about his “back to the bedside” initiative in the President's Message in the June 2017 ACP Internist. It is difficult not to sound too old-fashioned, but I also believe in the essential role of the physician-patient relationship. This critical relationship is enhanced by the physician's skill and experience at obtaining an appropriate and thoughtful history and by performing a physical examination that reveals detailed knowledge of the anatomy and physiology of the body systems in question.

Listening and thinking are still what patients expect from their physicians. Emphasizing this approach may not only be a way to achieve an economic advantage, but it may also help to restore the healing relationship that we have always enjoyed with our patients.

Frank Sparandero, MD, MPH, FACP

Bel Air, Md.

Debating the ‘insurocracy’

I read with great interest the President's Message in the July/August ACP Internist, “Consider seniors and the role they may play in ACP.” As a very senior member, I'd like to offer some suggestions, and my help.

Twelve years ago I hung up my stethoscope for good, ending my first career in medicine. Five years later I commenced my second, that of a patient. Nine operative procedures with their aftercare, between-care, and rehabilitation have kept me busy and given me a chance to view the temple of doom from the inside. I could tell many stories.

I've had excellent medical care. Why shouldn't I? I'm an (ex-)physician, my son, daughter-in-law, grandson, and granddaughter-in-law are all in practice, and a second grandson is in his fourth year of medical school. I do not lack for advocacy. My insurance is second to none. Indeed, I have no cause for complaint, yet still I am uneasy. I can't help feeling I'm on the winning side of a zero-sum game and am benefiting at the expense of others.

I'll provide as an example my latest bill for the laboratory work attendant on my wife's annual physical. The tests were urinalysis, complete blood count, and metabolic and lipid panels. My “copay” of $49.43 would, I imagine, nearly cover the expense of performing the tests. Yet the bill is $924! The vendors never provide an itemized breakdown or cost basis. Sometimes it's not even clear what they're charging for.

So why do I pay so little, if indeed the bill is legitimate? One reason is that the vendors make a contractual adjustment of $575.36, a writeoff of over 60%. The insurance pays 85% of the remainder, leaving the copay for me.

I don't know how the insurer secures the “adjustment,” but the first impression is that the “charge” is grossly and spuriously inflated.

More troubling is the thought that the uninsured, without an insurer to “negotiate” a writeoff, are stuck with the whole bill. These, who are least able to afford care, are hit with a surcharge of more than 100%. Also, I hear of others, with inferior plans, who must endure mountainous premiums, crushing deductibles, and copays.

The vendors are very careful. They make sure I have paid-up insurance at the door. And those who don't, are they denied care? Subjected to predatory collection practices? Discouraged from even seeking care? In their place I'd probably be dead, my wife blind, and both bankrupt.

This example is but the tip of the iceberg. When I begin to examine the monetary and administrative practices of my caregivers, it conjures images of the entrance to Dante's inferno.

I find these inequities obscene, the more so since our nation, the wealthiest in history, is the sole developed country that imposes them. I think ACP, among others, needs to combat them through advocacy and exposure of our insane “insurocracy.”

I am ready to help. I am ready to bare my medical and billing history in that effort, and offer my analyses.

Although as a career Veterans Affairs physician I have never been in the business of medicine, I understand that the insurocracy also makes onerous demands of practitioners, enslaving them to an electronic system designed for profit, not care. Other physicians, once in private practice, would be of great help in this area. I'm sure they, like me, are anxious to help.

Ira D. Stein, MD, FACP

Sharon, Mass.