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Bartering For Medical Care: A Chicken For A Checkup?

In the annals of “Things You Probably Wish You Hadn’t Said,” Sue Lowden, the Republican candidate to replace Nevada Senator Harry Reid, suggested last week that bartering for medical care was a workable substitute for the Affordable Care Act, which she is campaigning to repeal.

Surprisingly, after being called out and roundly mocked for the suggestion, she doubled down on the idea:

“You know, before we all started having healthcare, in the olden days, our grandparents, they would bring a chicken to the doctor. They would say, ‘I’ll paint your house.’”

I know that it’s hardly fair to pile on someone running for office for a bit of stump-speech dumbassery, but it just needs to be said. As much as I enjoy a nice chicken sandwich from time to time, barter is not a feasible mode of payment for services anymore. A doctor can’t pay his staff, his rent, or his malpractice insurance in chickens. 

A related suggestion was the idea of patients negotiating the price for services directly with their doctors. This also fails the giggle test on a number of levels. 

First of all, that is one of the advantages of belonging to an insurance program — they do the negotiating for you, and because of their size they command much deeper discounts than any individual ever could. This assumes that a doctor even cares to discuss price with an individual patient. I never do this in the ER, not only because of the circumstances, but because I honestly don’t know in advance exactly which of the thousands of codes (and prices) a given patient interaction will result in. Moreover, without the protection of insurance, the likelihood that any private individual will be able to afford the cost of an ER visit — let alone a surgery or hospitalization – is essentially nil.

It’s depressing to realize that there’s a substantial likelihood that this dimwit will be the next senator from Nevada.

Update: Also, it was noted that her history includes a malicious indifference to the healthcare needs of those less fortunate than herself: When Sue Lowden headed a Santa Fe hotel and casino, management forced a group of workers to shift to part-time status and sign away their healthcare coverage, said a judge who ruled that the company violated fair labor practices. 

Nice. That’s a real charmer you’re sending to the senate, Nevada.

*This blog post was originally published at Movin' Meat*

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One Response to “Bartering For Medical Care: A Chicken For A Checkup?”

  1. Matthew Bowdish MD says:

    I am not sure this dimwit will be any worse than the current one in that seat.

    But I have to take issue with you on your belief that empowering patients to become better medical consumers will not drive down health care costs. Real world data doesn’t seem to support that argument.

    Now, EDs are not exactly the place where you would expect market forces to be beneficial, nor is OR, which is why I think your examples are somewhat irrelevant. We definitely should have insurance for such catastrophic events as ED/OR visits. That’s really what ‘insurance’ is…a bet on the chance that one might have a heart attack, or cancer, or appendicitis.

    However, I would argue that routine primary care activities could use a health dose of market forces and more consumer skepticism. For example, I am an allergist. As such, I know that I would like to offer a number of services that my patients that might give them (and me) more info on their condition. But I am under no illusion that most of what I offer is absolutely medically-necessary. Why check five tree pollen skin tests when I can do one tree mix test? Yes, the added info is helpful, but is it worth the cost? I wrestle with these kind of decisions everyday. I also find that my patients often will say ‘more is better,’ especially if the insurance company is paying for it. If they paid for it, they would be more discerning on what really important to them.

    Furthermore, your argument that insurance companies are advocates FOR patients doesn’t really hold. They are, more often than not, acting at limiting access to care rather than effectively or compassionately negotiating for patients, most of whom don’t pay for their insurance but get it through the real payers….their employers. Needless to say, all of these third parties lead to a rather skewed interaction where the patient is often left out of the loop.

    If a patient has say, a consumer-driven health care plan (CDH) that operates both as true insurance (covering catastrophic issues) and allows the patients to control and guide his/her own routine health care dollars, then costs can be driven down.

    For example, a study released last year by the American Academy of Actuaries proved as much.

    The AAA showed CDHs decrease costs an average of 12-21% over traditional insurance plans. Introducing true market pressure into an industry where doctors like yourself self-admittedly don’t even understand the true costs of their work can only help save patients money.

    But you may retort that patients would then neglect primary care with such market pressures. Interestingly, that’s not the case. The same study found that when patients took a greater role in their health care decision making, and were able to affect its cost, they underwent ‘needed’ screening. Furthermore, the care they received also tended to conform better to evidence-based standards than did the care they received under traditional insurance. When push comes to shove, patients learn what is important and extract the maximal amount of value in the patient-physician interaction.

    Now on to the point that started me reading your article-bartering. I have on occasion taken bartered items from my patients in exchange for my services. That’s easier to do as a physician working in a private practice rather then your experience as, essentially, an employee of a hospital emergency department.

    While one cannot completely run a business through bartering alone, in some circumstances it has allowed my patients to get care they need while I have been able to be reimbursed for my labor. Accordingly, I wouldn’t mock such interactions as they really connect me and my patients in relationships that I have found much more meaningful that waiting for a check from Aetna.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

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Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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