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Fam Pract Manag. 2001;8(4):49

Patient advocate

When the phone rings at 11:00 at night, I know it's the hospital and I only hope I don't have to go in. This time, it was worse. As though in a dream, I heard my son who's away at college say, “Hey, Dad, were you sleeping? Yeah, well I've got some bad news. I broke my clavicle – but I'm OK. I just got back from the emergency room.” Well, I thought, it can't be too bad if Gabe's calling me himself, rather than having a doctor or police officer do it. “What happened?” I asked.

“Lost it going down a steep hill on the mountain bike. Hit a tree. Pretty major impact. Heard it break. Think I shook some birds' nests down too.”

They put him in a figure eight and doped him up on Percocet and Vicodin. The next day I called the hospital's radiologist and asked him about Gabe's X-ray. “It's as bad a clavicle fracture as I've seen,” he said. “The bones are overriding, and there's a 3 centimeter displacement and a vertical spicule besides.” That was enough; I called Gabe and told him to find an orthopod.

He called the orthopedist he had been referred to upon leaving the hospital and the receptionist set him up to see the physician's assistant. (I confess I pulled rank and asked that he be allowed to see the doctor.) The good news, Gabe reported afterward, was that the second X-ray, with him wearing the brace, looked much better; the bad news was that he was going to need minor surgery to remove the bone fragment. It was scheduled for the next week.

Doctors' kids are always the exception to the rule, I thought. I'd seen dozens of mid-shaft clavicular fractures during my tenure as an ER physician, and none ever required surgery. We gave them a brace, a sling, analgesics and a referral and assumed they all healed. Was Gabe's really that bad? I ran it by my orthopedic colleagues and the consensus was that the ends would probably mold with the bone fragment and, if there was a non-union, there would be time to fix it later. “Gabe,” I said, “my colleagues say to wait. They've got 40 years of orthopedic experience between them, so I vote to postpone the surgery. They say they've never seen that sort of bone fragment compound and taking it out won't make it feel any better but will create an infection risk.”

Gabe ran it by his doctor, and he graciously agreed to wait. I patted myself on the back for being such a good patient advocate and helping Gabe avoid unnecessary surgery and reminded myself to work harder to represent all my patients the way I had my son. Then, two weeks later, Gabe phoned to say the bone had broken through the skin, and 40 years of orthopedic experience went right down the drain. His doctor was kind, didn't even imply “I told you so,” and made arrangements to take out the fragment the next day. To my great relief, his minor surgery went smoothly, and I reminded myself how hard it must be for a doctor to take care of another doctor's child, especially when it happens to be mine.


It finally happened. After years of receiving truncated payments from insurance companies while my patients face rising co-payments, I just received a notice from an insurance company telling me that, because my patient's co-pay amount equaled my charge for the visit, the insurer owed me nothing. This presented several conundrums. When your charge for an office visit is less than the patient's co-pay, which amount does the patient pay? When your charge exceeds the co-pay, but the insurance company's adjusted amount for the visit is less than the co-pay, which amount does the patient pay? In short, is the co-pay always the co-pay?

To establish whether the co-pay is immutable or variable, I called several of my insurers. One told me that, in the event the adjusted amount is less than the patient's co-pay, I could only take the lesser amount. This becomes problematic as I rarely know the adjusted amount in advance. I suppose I could send my patient a refund after the explanation of benefits arrived with a little note saying, “Your $45 co-pay exceeds my charge for your visit. You are paying outrageous premiums for health insurance, and you're paying for office visits to boot, while your insurer is building skyscrapers with your money. Sucker. Do yourself a favor and get a catastrophic illness policy with a $2,000 deductible.”

The other thing my patients don't understand is that they are required to give me their co-pays at the time of service. “Bill me,” they'll say, on their way out the door.

“Wait a minute,” I've trained Isabel, my office manager, to say. “Did you know you have to pay your co-pay every time you come to the office? It's in your contract. We are required to take it.” For the few who aren't swayed by this argument, we say, “Do you know what happens when you drive past the toll booth without depositing your coins? It's the same way here and, believe us, you don't want to go there.”

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Copyright © 2001 by the American Academy of Family Physicians.

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