It's All About Money

I sent one of my middle-aged patients with psoriatic arthritis for electromyography, suspecting that the numbness and tingling he described in his hands was due to carpal tunnel syndrome. A few days later I got a report back from the neurologist that read, "moderate median nerve entrapment in both wrists," confirming my clinical suspicion. I told the nurse to ask him to try sleeping with resting wrist splints.

About 3 months later, the patient called back in a snit and told the nurse to let me know that the cost of the EMG was over $7,000 and his out-of-pocket portion of the bill was $800. Perhaps I’d gone into the wrong medical specialty, I mused. I suppose if I didn’t like this patient, I could insist on repeating the EMG every 3 months as a financial phlebotomy until he fled the practice or filed for bankruptcy.

Politicians are always talking about the millions of people in the United States who don’t have health insurance. What I don’t hear much talk about are the millions more whom I call the "underinsured." These poor souls have nominal health insurance. The coverage is so skimpy that almost any procedure or prescription ends up soaking the patient for big out-of-pocket expenses.

I had known that EMGs were expensive, but this was a bit of sticker shock even for me. That’s one of the intrinsic defects in our current health care system. Everyone is spending money while blissfully ignorant of the price tags. Patients and doctors both need to have an awareness of what things cost and a financial incentive to save money. I’ve noticed that the uninsured do this as a matter of survival. After this episode, I’m a little more prudent when I order an EMG. First, I find out how much it will cost, and then I tell the patient to check what part of the bill their insurance will cover.

There are alternatives to EMG. I could do an ultrasound exam and see if there is sonographic evidence of median nerve compression, but I suspect that even if I could do a good job, sending the patient and my ultrasound images to a surgeon, the surgeon would order an EMG anyway. As another alternative, I could send the patient to see a surgeon without ordering an EMG. Let the surgeon order it and incur the wrath of the patient stricken with the bill. That feels a bit sneaky, but I’ve been successfully using the same strategy with shoulder and knee MRIs for years. Let the orthopedist order whatever they need, I tell my patients.

Another one of my patients has chronic neck pain. Although this is not the same as a chronic pain in my neck, the difference can be subtle. He came back to tell me that he had given up on his pain specialist and he wanted me to resume prescribing his pain medication for him. The pain specialist had been happy to perform this function for a few months while he was busily injecting my patient. The patient told me that he had a total of three epidural steroid injections (ESI) for his neck pain. The first injection had been some help, but the next two didn’t help at all. His insurance covered his ESI injections at 100%, but he still ended up with about $1,000 in medical bills due to his part of the cost of his MRI scan, and other expenses. The pain specialist was confident that he could help my pain in the neck, I mean my patient, with a nerve branch block but the patient didn’t want to try this, since his insurance only covered 80% of this procedure. My patient said the cost was $5,000 a shot, and by this time I was sure I must be in the wrong specialty. My patient figured the pain relief he might get out of these more expensive injections was questionable, but the bills he would incur were a certainty, so he dumped the pain specialist and came back to see me. Scenarios like this play themselves out in my office all the time.

Another patient, a long-haul truck driver, came back to see me for his annual follow-up. His blood pressure was high, but he reassured me that it was from the stress of seeing my white coat and my smiling face. He was certain his blood pressure was lower when he was driving his truck through heavy traffic. I wasn’t really happy about scheduling his follow-up appointment a full year from now, but that’s another kind of economy that patients frequently insist on taking.

While we were discussing these issues, I read my progress notes. At his last visit, he had a skin lesion at the base of his nose that I thought was a skin cancer. Since the cancer was in the center of his face, I thought he should have this removed by a plastic surgeon. It turned out that the lesion was a basal cell carcinoma. The plastic surgeon had removed the lesion very skillfully, and without leaving a scar. I was impressed, and I told my patient that the plastic surgeon had done a fabulous job. Perhaps on some subconscious level I was fishing around for a compliment or a thank you. Many times patients come back after I have referred them to a cardiologist or some other specialist. They thank me profusely for saving their life, even though sending someone with crushing chest pain to a cardiologist or the emergency department is a real "no brainer." In my opinion, this judgment call seemed a little bit more sophisticated. While I was wrapped up in this self-congratulatory reverie, my patient rudely brought me back to reality. He conceded that the plastic surgeon had done a great job, but with his $3,000 deductible, he whined that his out-of-pocket costs were $2,800. I guess it would have been cheaper to cut his nose off, but I didn’t say so, because I didn’t want to give him any ideas on how he might save money in the future.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. This column, "Inside Rheum," appears regularly in Rheumatology News, a publication of Elsevier.

I sent one of my middle-aged patients with psoriatic arthritis for electromyography, suspecting that the numbness and tingling he described in his hands was due to carpal tunnel syndrome. A few days later I got a report back from the neurologist that read, "moderate median nerve entrapment in both wrists," confirming my clinical suspicion. I told the nurse to ask him to try sleeping with resting wrist splints.

About 3 months later, the patient called back in a snit and told the nurse to let me know that the cost of the EMG was over $7,000 and his out-of-pocket portion of the bill was $800. Perhaps I’d gone into the wrong medical specialty, I mused. I suppose if I didn’t like this patient, I could insist on repeating the EMG every 3 months as a financial phlebotomy until he fled the practice or filed for bankruptcy.

Politicians are always talking about the millions of people in the United States who don’t have health insurance. What I don’t hear much talk about are the millions more whom I call the "underinsured." These poor souls have nominal health insurance. The coverage is so skimpy that almost any procedure or prescription ends up soaking the patient for big out-of-pocket expenses.

I had known that EMGs were expensive, but this was a bit of sticker shock even for me. That’s one of the intrinsic defects in our current health care system. Everyone is spending money while blissfully ignorant of the price tags. Patients and doctors both need to have an awareness of what things cost and a financial incentive to save money. I’ve noticed that the uninsured do this as a matter of survival. After this episode, I’m a little more prudent when I order an EMG. First, I find out how much it will cost, and then I tell the patient to check what part of the bill their insurance will cover.

There are alternatives to EMG. I could do an ultrasound exam and see if there is sonographic evidence of median nerve compression, but I suspect that even if I could do a good job, sending the patient and my ultrasound images to a surgeon, the surgeon would order an EMG anyway. As another alternative, I could send the patient to see a surgeon without ordering an EMG. Let the surgeon order it and incur the wrath of the patient stricken with the bill. That feels a bit sneaky, but I’ve been successfully using the same strategy with shoulder and knee MRIs for years. Let the orthopedist order whatever they need, I tell my patients.

Another one of my patients has chronic neck pain. Although this is not the same as a chronic pain in my neck, the difference can be subtle. He came back to tell me that he had given up on his pain specialist and he wanted me to resume prescribing his pain medication for him. The pain specialist had been happy to perform this function for a few months while he was busily injecting my patient. The patient told me that he had a total of three epidural steroid injections (ESI) for his neck pain. The first injection had been some help, but the next two didn’t help at all. His insurance covered his ESI injections at 100%, but he still ended up with about $1,000 in medical bills due to his part of the cost of his MRI scan, and other expenses. The pain specialist was confident that he could help my pain in the neck, I mean my patient, with a nerve branch block but the patient didn’t want to try this, since his insurance only covered 80% of this procedure. My patient said the cost was $5,000 a shot, and by this time I was sure I must be in the wrong specialty. My patient figured the pain relief he might get out of these more expensive injections was questionable, but the bills he would incur were a certainty, so he dumped the pain specialist and came back to see me. Scenarios like this play themselves out in my office all the time.

Another patient, a long-haul truck driver, came back to see me for his annual follow-up. His blood pressure was high, but he reassured me that it was from the stress of seeing my white coat and my smiling face. He was certain his blood pressure was lower when he was driving his truck through heavy traffic. I wasn’t really happy about scheduling his follow-up appointment a full year from now, but that’s another kind of economy that patients frequently insist on taking.

While we were discussing these issues, I read my progress notes. At his last visit, he had a skin lesion at the base of his nose that I thought was a skin cancer. Since the cancer was in the center of his face, I thought he should have this removed by a plastic surgeon. It turned out that the lesion was a basal cell carcinoma. The plastic surgeon had removed the lesion very skillfully, and without leaving a scar. I was impressed, and I told my patient that the plastic surgeon had done a fabulous job. Perhaps on some subconscious level I was fishing around for a compliment or a thank you. Many times patients come back after I have referred them to a cardiologist or some other specialist. They thank me profusely for saving their life, even though sending someone with crushing chest pain to a cardiologist or the emergency department is a real "no brainer." In my opinion, this judgment call seemed a little bit more sophisticated. While I was wrapped up in this self-congratulatory reverie, my patient rudely brought me back to reality. He conceded that the plastic surgeon had done a great job, but with his $3,000 deductible, he whined that his out-of-pocket costs were $2,800. I guess it would have been cheaper to cut his nose off, but I didn’t say so, because I didn’t want to give him any ideas on how he might save money in the future.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. This column, "Inside Rheum," appears regularly in Rheumatology News, a publication of Elsevier.

I sent one of my middle-aged patients with psoriatic arthritis for electromyography, suspecting that the numbness and tingling he described in his hands was due to carpal tunnel syndrome. A few days later I got a report back from the neurologist that read, "moderate median nerve entrapment in both wrists," confirming my clinical suspicion. I told the nurse to ask him to try sleeping with resting wrist splints.

About 3 months later, the patient called back in a snit and told the nurse to let me know that the cost of the EMG was over $7,000 and his out-of-pocket portion of the bill was $800. Perhaps I’d gone into the wrong medical specialty, I mused. I suppose if I didn’t like this patient, I could insist on repeating the EMG every 3 months as a financial phlebotomy until he fled the practice or filed for bankruptcy.

Politicians are always talking about the millions of people in the United States who don’t have health insurance. What I don’t hear much talk about are the millions more whom I call the "underinsured." These poor souls have nominal health insurance. The coverage is so skimpy that almost any procedure or prescription ends up soaking the patient for big out-of-pocket expenses.

I had known that EMGs were expensive, but this was a bit of sticker shock even for me. That’s one of the intrinsic defects in our current health care system. Everyone is spending money while blissfully ignorant of the price tags. Patients and doctors both need to have an awareness of what things cost and a financial incentive to save money. I’ve noticed that the uninsured do this as a matter of survival. After this episode, I’m a little more prudent when I order an EMG. First, I find out how much it will cost, and then I tell the patient to check what part of the bill their insurance will cover.

There are alternatives to EMG. I could do an ultrasound exam and see if there is sonographic evidence of median nerve compression, but I suspect that even if I could do a good job, sending the patient and my ultrasound images to a surgeon, the surgeon would order an EMG anyway. As another alternative, I could send the patient to see a surgeon without ordering an EMG. Let the surgeon order it and incur the wrath of the patient stricken with the bill. That feels a bit sneaky, but I’ve been successfully using the same strategy with shoulder and knee MRIs for years. Let the orthopedist order whatever they need, I tell my patients.

Another one of my patients has chronic neck pain. Although this is not the same as a chronic pain in my neck, the difference can be subtle. He came back to tell me that he had given up on his pain specialist and he wanted me to resume prescribing his pain medication for him. The pain specialist had been happy to perform this function for a few months while he was busily injecting my patient. The patient told me that he had a total of three epidural steroid injections (ESI) for his neck pain. The first injection had been some help, but the next two didn’t help at all. His insurance covered his ESI injections at 100%, but he still ended up with about $1,000 in medical bills due to his part of the cost of his MRI scan, and other expenses. The pain specialist was confident that he could help my pain in the neck, I mean my patient, with a nerve branch block but the patient didn’t want to try this, since his insurance only covered 80% of this procedure. My patient said the cost was $5,000 a shot, and by this time I was sure I must be in the wrong specialty. My patient figured the pain relief he might get out of these more expensive injections was questionable, but the bills he would incur were a certainty, so he dumped the pain specialist and came back to see me. Scenarios like this play themselves out in my office all the time.

Another patient, a long-haul truck driver, came back to see me for his annual follow-up. His blood pressure was high, but he reassured me that it was from the stress of seeing my white coat and my smiling face. He was certain his blood pressure was lower when he was driving his truck through heavy traffic. I wasn’t really happy about scheduling his follow-up appointment a full year from now, but that’s another kind of economy that patients frequently insist on taking.

While we were discussing these issues, I read my progress notes. At his last visit, he had a skin lesion at the base of his nose that I thought was a skin cancer. Since the cancer was in the center of his face, I thought he should have this removed by a plastic surgeon. It turned out that the lesion was a basal cell carcinoma. The plastic surgeon had removed the lesion very skillfully, and without leaving a scar. I was impressed, and I told my patient that the plastic surgeon had done a fabulous job. Perhaps on some subconscious level I was fishing around for a compliment or a thank you. Many times patients come back after I have referred them to a cardiologist or some other specialist. They thank me profusely for saving their life, even though sending someone with crushing chest pain to a cardiologist or the emergency department is a real "no brainer." In my opinion, this judgment call seemed a little bit more sophisticated. While I was wrapped up in this self-congratulatory reverie, my patient rudely brought me back to reality. He conceded that the plastic surgeon had done a great job, but with his $3,000 deductible, he whined that his out-of-pocket costs were $2,800. I guess it would have been cheaper to cut his nose off, but I didn’t say so, because I didn’t want to give him any ideas on how he might save money in the future.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. This column, "Inside Rheum," appears regularly in Rheumatology News, a publication of Elsevier.