Patient satisfaction

February 24

When a medical record release form arrives in our mail, we know we've had, in some way, a breakdown in the doctor-patient relationship. The cause is almost never a misdiagnosis or a clinical mistake; rather, it's a front-office problem, a failure to communicate and to address the patient's concerns, or something so arcane that it defies my imagination. Recently, we swallowed our pride and began calling those patients to ask why they've left. It isn't easy to do, but it's always better knowing and it helps us improve our service.

Last week we received a request for records from another office on a 27-year-old man we had just seen for hemoptysis and chronic chest pain. I had diagnosed bronchitis as the cause of his blood-tinged sputum, but the chest X-ray had shown mild cardiomegaly. In addition, his history included a severe bout of pericarditis and a subsequent echocardiogram and cardiac cath. It was complex enough that I referred him to a cardiologist. Isabel left word with the cardiologist's answering service to call the patient, leaving his demographic information and pertinent medical history. Ten days later, the medical record request arrived.

When we contacted the patient, we learned that the cardiologist's scheduler had never called him back, and in frustration he went to another office for a referral. He wasn't unhappy with us and had in fact planned to continue coming to us for his primary care. I was relieved, particularly that he hadn't had a major coronary event in the interim, but I also felt that the patient was remiss in not calling us back. Nevertheless, I instructed Isabel that with future referrals we should speak directly to a scheduler or secretary and let our patients know to contact us if they don't receive their appointments in a timely fashion. Some things are easy to fix.

Health insurance

March 1

A patient asked me today what kind of health insurance he should buy. To his surprise, I told him that the best policies (for patients, not doctors) are often the least expensive, thanks to managed care and negotiated fee contracts.

Last year I sustained a meniscal tear riding my dirt bike, and when it worsened to the point where I couldn't flex my leg, I realized I was facing knee arthroscopy and a large medical bill. My policy was for major medical services only and had a high deductible, so I was expecting to pay the first $2,000 and 20 percent of the remaining balance. I had the procedure done at an outpatient surgery center, employing a surgeon and an anesthesiologist. Several weeks later, the bills arrived: $5,325 for the surgery center, $1,600 for the surgeon and $625 for the anesthesiologist. But all bills had to go through my insurance company first, since all the principals were “preferred providers,” a euphemism meaning they agreed to accept the payment that was allowed, in exchange for the business, and would not come back to the patient for the difference.

When my explanation of benefits arrived, the bill for the surgery center had dropped $4,182, making my share only $1,143. “Get out of town!” I thought to myself. In addition, the surgeon's bill was truncated over 50 percent, as was the anesthesiologist's. In an ironic turn of events, my relatively inexpensive, no-frills policy had saved me the most money because my providers had agreed to accept the low fee schedule. It then occurred to me how to buy health insurance in the era of managed care: Find the policy with the lowest procedural reimbursements accepted by your health care providers, because that should have the lowest premiums and save you the most money.

Being a primary care “preferred provider” myself, I often grouse about managed care and my declining reimbursements. But as a health care consumer, even I can't resist a bargain.

Dem bones

March 7

As a family physician, I enjoy doing an occasional surgical assist. About once a month is fine with me, and please let the case last no more than two hours. Anything longer or more frequent makes me fidget and experience low-back pain; anything less often causes me to fret about losing my retraction and suctioning skills.

I was helping my orthopedic colleague Charlie do a total hip replacement this morning when a droll event occurred, reminding me just why it's so much fun to assist. The patient was a big man, and Charlie, after dislocating the patient's femur, was having a bit of trouble removing the sawed-off femoral head. He reinserted the bone hook and pulled hard, but it wouldn't budge. So he pulled harder and harder, until it flew out of the hole, sailed across the room, bounced a few times and finally came to rest at the float nurse's feet. Everyone but Charlie had to fight back their laughter, until finally he broke the silence. “Don't worry about that one,” Charlie said dryly. “I wasn't planning on using it again.”