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We’ve all done it, arrive early on the pretense everyone’s so busy they can’t be kept waiting. But then our fifteen minute wait slowly twitters toward thirty, and as the clock agonizingly inches toward the forty-five-minute mark, suddenly you’re called. Your first reaction is to exhale loudly and proclaim, “finally!” But you do it just loud enough for the impatient woman beside you with her fidgeting child who’s never been properly trained on public etiquette to hear you, but not so loud as to offend office staff. Your moment of premature joy is shattered though when you realize the reason you’ve been culled from the herd is so you can complete your agonizing wait in isolation.
Having raised three children, helped my Dad through several operations, and had my share of emergency room repairs, I’ve observed medical professionals follow a prescribed script from which they seldom deviate. In fact, the script is so predictable it has to come from training. I first noticed the pattern when my wife was pregnant with her second child. While her OBGYN amused us with an exam at the start of each visit, by the end of the visit, regardless of my wife’s condition, we were being prescribed the exact same test and/or drug as we did during that stage of her first pregnancy, even though we were now with a different doctor. It sort of made sense, after all, pregnancies are pretty routine and why not test a twenty-two year old Mom for diabetes when she presents no indicators, after all insurance covers it and doctors need to make a living same as anyone.
Nine months on though, I started singing a different tune. Logic dictates that surely there’s differences between a first and second pregnancy that necessitating script deviation. Little did I know I would be the one jumping the tracks when I asked the doctor to induce labor a week early. As fate happened, it was two days before New Year’s and I wanted my son delivered that year so I could get the tax write off. Think about it, if he’s born before December 31st, I get a quick two-grand in tax credits, but if he’s born after that, I lose my end of year bonus.
It was clear no one had ever asked this OBGYN to do induce labor for financial gain and while he tried to argue around medical reasons for waiting that one extra week, they didn’t really hold up. He initially struggled with the ethical implications of honoring my request, but in the end agreed to perform an additional exam that might inadvertently rupture the water bag. While the media always hypes the first baby born in the new year, by my calculus those parents just lost the lottery and two-grand buys a lot of diapers.
As I moved in and out of medical offices for various reasons over the years, I’ve developed a game around guessing what script we’ll be on and what kind of sales pitch I’ll be given. Of the three major reasons we usually see a doctor, Optometrist/Ophthalmologist pressure people to spend money less than they did years ago. It used to be when you went in for an eye exam you were pressured into buying glasses and contacts from the doctor. Now they hardly bother to sell you anything. I got my last glasses on-line for $25, which is way less than what I had been paying for doctor office glasses. Optometry has has probably had to reinvent themselves the most in order to stay profitable even though they seem the least impacted by technology. I say kudos to them for successfully restructuring their business model without sacrificing patient relationships.
General health practitioners are the next most to have undergone change. Today’s MD is a long way from the kindly old man who came to my house when I had chickenpox. Now days MDs have large offices with multiple doctors, physician assistants, nurse practitioners and a small army of office staff. Today’s MDs all work for the government even if they’re in denial. Government sets reimbursement rates and the only way to remain profitable is to see more patients or sell each patient more stuff. My experience is that most MDs try to cram more patients into their day, which means the amount of time they can spend with each person is reduced. An MD explained their profit model to me by saying doctors cannot spend more than five minutes with each patient.
While I’ve never felt over-pressured to buy a test or procedure, I have had to challenge MDs to justify their recommendations and I always get an estimate up front so we can work through the cost/benefit analysis together. My worst experience with an MD occurred after my wife and daughter were rear-ended in Taos and I took them to our doctor for a wellness check. Before going in I was told the visit would cost $75 each but the bill I got was for $750 each. When I challenged about the cost, he smugly told me I wasn’t qualified to challenge his billing practices. Well, all that marginal man got from me was the quoted $150. In return, I got a new doctor and a couple polite phone calls from a collection agency. We were already on shaky terms because I called before an early appointment to ask how late they were running, suggesting that I would just come later. I was told that I had to arrive at my appointed time regardless of how long I’d end up waiting. I in turn countered that if they knew they running an hour late, just tell me and I’ll come an hour later. “No,” was their answer, “you either arrive at your set time or we’ll charge you $100 for missing your appointment.”
I had a friend a few years back who along with his wife were both MDs working in different offices. We were all midcareer but the two of them combined had an annual income less than my engineering salary. Not only that, it seemed they were always on call and rarely got a weekend off. My daughter briefly talked about studying medicine in college, but I was able to talk her off that ledge. I would not want an MD’s life for her. “Be an engineer,” I told her, “less stress, better hours, more interesting work, and way more salary.“
Dentist/Orthodontists have experienced the largest change to their profession due to technology advances and the success they’ve had training us to take better care of our teeth. Cavities that were once a rite of passage have all but disappeared. Root-canal and wisdom teeth extraction is so advanced you’re in and out in no time with little discomfort. Three-D printing of crowns means you can go from root-canal to crown in a single visit. Digital x-rays and imaging have taken all the guess work out of diagnosis. Plastic liners that cost less to produce than a sports mouth guard are replacing conventional braces and with them, weekly adjustments are now done at home. All these advances chipped away at doctor’s bottom line causing them to scramble to find a profit model that worked. Implants are a new money maker, but the volume is so low it can’t sustain a practice.
Faced with the same dilemma as MDs, dentist opted to both see more patients and sell the patients they saw more stuff. Over the past several years the dental profession has aggressively adopted high-pressure tactics to get you to buy stuff you don’t really need. It has gotten so bad I’ve started changing doctors in search of one that won’t leave a bad taste in my mouth (sorry about that pun, it was just hanging there and I had to grab it).
The problem with their high-pressure sales pitch is we’ve all had tooth problems and are painfully aware we don’t need a dentist’s diagnosis to tell us there’s a problem; we just need them to fix it. My last bout of high-pressure sales involved being told I needed to replace old crowns. The doctor’s pitch was that after all those years the crowns could be leaking bacteria onto the tooth. There was no evidence this was happening but why run that risk, after all, insurance would cover half of the $3,000 it cost to replace the first crown. After that though, I would have to pay the full cost of the other replacements, but my doctor assured me we could work something out through his convenient payment plan.
Rather than proceed, I switched doctors and after my first checkup with the new guy, my old crowns were found to be in fine working order. There was however, according to the new guy, a tooth that needed to be removed and replaced with an implant. The tooth was not hurting, was not chipped, but in his best medical opinion, it was only a matter of time and following his sales script concluded, “we really want to be out in front of this.” Well I didn’t get that procedure and three years later my beloved tooth is still attached.
So off to another dentist in search of the illusive doctor more into patient care than perfecting his used car sales pitch. I found a new guy after a crown fell off and needed to be re-glued; only he declared the crown could not be re-glued and that the tooth needed to be removed and replaced with . . . you guessed it . . . an implant. That led to the next new guy who said the tooth could be saved but that a new crown was needed since the base of the old crown was worn. That the inside of a crown could get worn seemed a bit odd but I chose to proceed because I really wanted to get one of those new fangled 3D printed tooth’s. I love technology more than most and having a digitally mapped 3D printed tooth seemed too cool for school.
I was eager to get that bad boy knocked out in a single visit but my new doctor had a different strategy, he convinced me that since it was a back tooth 3-D printing was not optimal, even though everything I had read said printed teeth were stronger than traditional porcelain ones. But I let him talk me into to doing the crown the old-school way even though it was considerably more expensive and would take weeks to complete. Before we proceed though, I was smart enough to make him give me a detailed quote so I knew how much the entire bill would be.
So, he fits me for my crown, sends the mold off to get made, and three weeks later calls me back for installation. When everything’s done, I go to pay, and the bill is $1,800 above the quote. After arguing unsuccessfully with the office manager who said the bill, “is what it is, and I needed to pay it,” the dentist got looped in. We engage in a rather lengthy and far ranging conversation that concluded with him begrudgingly agreeing to honor his quote. Today though, three months after that unfortunate affair, I get a $1,200 bill from his office, apparently my insurance would not cover their portion of the old-school crown costs so I would need to. After I finished laughing at the business manager, I told her, and I quote, “I don’t think so.“
It bothers me that they probably get away with pulling stuff like this on other people who are less likely to argue. It also bothers me that this is not the first time I’ve had that line laid on me. I explained to the business manager that it’s their job to know what my insurance covers and does not cover and if they make a mistake it’s on them, not me. I also reminder her that I requested the less expensive 3D tooth, which according to her the insurance would have covered.
I’m sure that soon I’ll be getting a letter from some yet another polite collection agency warning me to pay the $1,200 bill or else my credit rating will be decimated. The thing about that though is I don’t really care if my credit score gets decimated, I’ve yet to figure out what its really even for. Show me a credit card agency or banker who doesn’t fall over themselves giving out credit like candy canes. I like to have fun with collection agencies by hoping that after my credit rating plummets I’ll stop getting those annoying credit card application promotions in the email. Ironically the less inclined I am to pay my bogus medical bills; the more emboldened credit card companies become.
Medicine has come a long way in my lifetime. Technology has made incredible advances and the pharmaceutical industry has reinvented therapy; but it has come at a cost. Gone are the days of Marcus Welby, MD, and doctors toiling away in their small offices treating patients like family. Gone are the days when doctors had patient care as their primary objective. The ethical dilemma of my wife’s OBGYN seems so quaint and long-ago considering today’s profit driven approach to medical office management. Gone are the days when medicine was a profession before becoming a business with office managers, payment plans, and collection agencies on speed dial. Gone are the days when medicine was guided by the Hippocratic Oath, unless that is if the financial wellbeing of patients is excluded from a doctor’s commitment to “do no harm.“