The Medical Thread: We're experts on everything else; why not?

[DrDemento]

I did. I couldn't recall anything that was handled that got a Derm out of bed. I was trying to think of something that only a Derm would handle - there has to be something- and was coming up blank. I was waiting for you to refresh me.

I got called for things like Stevens-Johnson syndrome, toxic epidermal necrolysis, some incredibly severe allergic reactions to all sorts of things but honestly, most of the midnight calls from the ER were for me to come see a patient and insure the doctors and nurses that what they were looking at was not contagious (that is was a allergic drug rash instead of scabies for example) as they were just afraid to catch something. Having trained as both an internist and a psychiatrist first, often times the emergency was something i had the advantage of an overall perspective. As the years went by, I spent most of my career as a skin cancer reconstructive surgeon and although most of the conditions I dealt with were serious, there really was virtually no emergent nature to any of them. A delay of a few hours certainly did not make a difference in the overall mortality or morbidity.
Honestly miss those years greatly but fully understand that the practice of medicine has now changed so much that much of the decision making would be removed from me and replaced by the insurance companies and the government.

 

[Swansong]

Honestly miss those years greatly but fully understand that the practice of medicine has now changed so much that much of the decision making would be removed from me and replaced by the insurance companies and the government.

I'll never make a clinical decision for anyone other than myself or perhaps someone for whom I am a proxy, but this still drives me nuts. The hoops you folks have to go through in order to get patients care they need without resulting in a zillion dollar bill are insane.

Insurance 1 requires steps A, B and C before approving the actual treatment Z.
Insurance 2 requires steps A, C and D before approving the actual treatment Z.
Insurance 3 requires step E to happen before steps A and B, but step E never happened so they'll never approve treatment Z.

And on and on. It's ridiculous. The last 15 years of EHRs have introduced clinical decision making tools to assist. The idea behind those is for underserved areas that perhaps don't have a Dermatologist on call to allow the local staff to make informed decisions. The reality is that we use them to make sure providers do the required bullshit for that patient's insurance company. One of the analysts that works for me spends 1/4 of his time making sure gaps in documentation are plugged just so we get reimbursed properly. And that's after 4+ years of being on this system. Claim denials for administrative reasons are the worst.

 

[DrDemento]

I'll never make a clinical decision for anyone other than myself or perhaps someone for whom I am a proxy, but this still drives me nuts. The hoops you folks have to go through in order to get patients care they need without resulting in a zillion dollar bill are insane.

Insurance 1 requires steps A, B and C before approving the actual treatment Z.
Insurance 2 requires steps A, C and D before approving the actual treatment Z.
Insurance 3 requires step E to happen before steps A and B, but step E never happened so they'll never approve treatment Z.

And on and on. It's ridiculous. The last 15 years of EHRs have introduced clinical decision making tools to assist. The idea behind those is for underserved areas that perhaps don't have a Dermatologist on call to allow the local staff to make informed decisions. The reality is that we use them to make sure providers do the required bull**** for that patient's insurance company. One of the analysts that works for me spends 1/4 of his time making sure gaps in documentation are plugged just so we get reimbursed properly. And that's after 4+ years of being on this system. Claim denials for administrative reasons are the worst.

This is why we now only do consulting work. And anything we do or anyone we see is all pro bono. i like to still diagnose and prescribe but fortunate that after 50+ years I can provide any care free. Before we did this, I would spend 4 hours a day seeing patients and 4 hours each day on the phone with the insurers or the medicare representatives. The only reason that my phone time was even this short was that Jenny (office nurse and manager) would handle the bulk of the approvals needed and arguing for patient reimbursement.
After 4 years of Medical school, a year of medical internship, 2 years of Medical residency, 3 years of Dermatology residency, a year of Psychiatry residency and a year of Plastic surgery and then 40+ years of experience in private practice - I just felt it too difficult to have to argue with some young lady on the phone who was popping gum while she spoke in order to provide proper medical care to my patients.

 

[Kepler]

This is why we now only do consulting work. And anything we do or anyone we see is all pro bono. i like to still diagnose and prescribe but fortunate that after 50+ years I can provide any care free.

You rock, man. You. Rock!

 

[Swansong]

This is why we now only do consulting work. And anything we do or anyone we see is all pro bono. i like to still diagnose and prescribe but fortunate that after 50+ years I can provide any care free. Before we did this, I would spend 4 hours a day seeing patients and 4 hours each day on the phone with the insurers or the medicare representatives. The only reason that my phone time was even this short was that Jenny (office nurse and manager) would handle the bulk of the approvals needed and arguing for patient reimbursement.
After 4 years of Medical school, a year of medical internship, 2 years of Medical residency, 3 years of Dermatology residency, a year of Psychiatry residency and a year of Plastic surgery and then 40+ years of experience in private practice - I just felt it too difficult to have to argue with some young lady on the phone who was popping gum while she spoke in order to provide proper medical care to my patients.

And that's the worst part. You'll never speak to the person that made the decision. You'll never speak to the person that designed the actuarial table, or the adjuster/case manager that (allegedly) read through your Utilization Review or clinical notes. You'll get that front-end person that, however well-meaning they may be, has no idea why your procedure is being denied and can provide no real help to you or the patient.

 

[WisconsinWildcard]

And that's the worst part. You'll never speak to the person that made the decision. You'll never speak to the person that designed the actuarial table, or the adjuster/case manager that (allegedly) read through your Utilization Review or clinical notes. You'll get that front-end person that, however well-meaning they may be, has no idea why your procedure is being denied and can provide no real help to you or the patient.

I recently spent >1 hour explaining to some insurance company why I wanted a particular MRI. They wanted me to diagnose the patient with a certain kind of nerve tumor so it would be approved. I kept saying that is why I am getting the MRI in the first place, in order to see if there is a tumor, but the actuarial table stated they had to have a known tumor to get the MRI approved. I am a subspecialist so by definition, I see very focused and rare diseases, so very often the insurance company representative has never heard of the disease they are arguing with me about.

Retirement plan is similar to Dr. D but on a shorter time scale. FIRE then do what I actually enjoy doing in medicine without a care for money.

 

[Swansong]

I recently spent >1 hour explaining to some insurance company why I wanted a particular MRI. They wanted me to diagnose the patient with a certain kind of nerve tumor so it would be approved. I kept saying that is why I am getting the MRI in the first place, in order to see if there is a tumor, but the actuarial table stated they had to have a known tumor to get the MRI approved. I am a subspecialist so by definition, I see very focused and rare diseases, so very often the insurance company representative has never heard of the disease they are arguing with me about.

Retirement plan is similar to Dr. D but on a shorter time scale. FIRE then do what I actually enjoy doing in medicine without a care for money.

Ugh. Is there no screening test available to you? There are other tests like the PSA that require a screen before a diagnostic, and insurance won't reimburse if you do the diagnostic before (or even at the same time as) the screen.

What makes that PSA situation so silly is that they're the EXACT SAME TEST at the lab. But for insurance purposes we have to have two records built out, that link to two different workflows, and try to convince every provider to order them sequentially so that phlebotomists don't try to draw them concurrently.

 

[ScoobyDoo]

I recently spent >1 hour explaining to some insurance company why I wanted a particular MRI. They wanted me to diagnose the patient with a certain kind of nerve tumor so it would be approved. I kept saying that is why I am getting the MRI in the first place, in order to see if there is a tumor, but the actuarial table stated they had to have a known tumor to get the MRI approved. I am a subspecialist so by definition, I see very focused and rare diseases, so very often the insurance company representative has never heard of the disease they are arguing with me about.

Retirement plan is similar to Dr. D but on a shorter time scale. FIRE then do what I actually enjoy doing in medicine without a care for money.

This is why we need single payer. Insurance companies are a joke.

 

[The Sicatoka]

If we, as a country, were honest with ourselves we'd admit that the mental health pandemic makes covid-19 look like a piker.

 

[The Sicatoka]

This is why we need single payer. Insurance companies are a joke.

Nobody likes insurance companies. --> Motto: Give me your money and I'll give it back when I think you need it. < glare >

But are we sure folks in single-payer places are getting the scans/treatment they need in any more timely a manner?

(I fully discount the urban legends of Canadians coming to Roseau or Grand Forks for treatment. That ain't real.)

 

[French Rage]

concern!

 

[ScoobyDoo]

concern!

It is almost like America is just a complete shithole and no problems with any system can be overcome and made better for the citizens. Republicans are starting to make everyone believe that. And it's pretty sad.

 

[The Sicatoka]

Toss out 'single payer' as the solution.
But look back at these pages of self-critique of medical professionals by medical professionals admitting the biases and shortcomings in the existing system of medicine.

You can't use single-variate thinking on a multi-variate problem like this. There is no magic bullet. Insurance needs to be fixed; the profession needs to be fixed. The way we all view and use medicine and (personal) healthcare needs to be fixed.

 

[Kepler]

Toss out 'single payer' as the solution.

No.

 

[psych]

Toss out 'single payer' as the solution.
But look back at these pages of self-critique of medical professionals by medical professionals admitting the biases and shortcomings in the existing system of medicine.

You can't use single-variate thinking on a multi-variate problem like this. There is no magic bullet. Insurance needs to be fixed; the profession needs to be fixed. The way we all view and use medicine and (personal) healthcare needs to be fixed.

I don’t think single-payer is the answer, but universal healthcare certainly is.

 

[Kepler]

I don’t think single-payer is the answer, but universal healthcare certainly is.

So is the end of insurance.

We don't pay insurance for our police or military or clean air.

Socialize needs. Privatize wants. There should be no profit motive in things everyone must have to live.

 

[Deutsche Gopher Fan]

I don’t think single-payer is the answer, but universal healthcare certainly is.

Ans there are tons of permutations on how to fund. Germany Switzerland France etc.

thidbis one of my stress of expertise but I’ll wait and be mansplained to by concerned people

 

[SJHovey]

Socialize needs. Privatize wants. There should be no profit motive in things everyone must have to live.

Don't people need food and shelter way more than they need healthcare to live?

 

[Deutsche Gopher Fan]

Don't people need food and shelter way more than they need healthcare to live?

Is there a reason that they can’t all be in the same category?

 

[SJHovey]

Is there a reason that they can’t all be in the same category?

In a broad sense, maybe. Personally I think that there should be a certain level of those items that needs to be socialized, instead of just socializing the entirety of them.