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The Win-Win Referral

One of my patients is an elderly woman who is completely bedbound due to osteoarthritis. Since she’s considered “too old,” she isn’t considered a surgical candidate for a knee replacement. Her son, George, is her caregiver.

George had been referred to our practice through word-of-mouth from a geriatric care consultant. When he called me for an initial visit, his mother had a spot on her left forearm that was growing rapidly. The nodule was red and tender. Both of them wanted a doctor to look at and remove it, and at the house if possible.

Before we agreed to an appointment time, I explained to George how our payment system operated: We ask for payment at time of service. Our first housecall usually costs $300 for a 30 minute consult, with our fees being time based just like most services.

Our practice has opted out of Medicare so we can provide a service that our patients can control, including the ability to reach a practitioners the instant help is needed, which means 24/7 access to a medical expert whenever needed.  However, opting out of Medicare means I’m a person non-grata to the Medicare system.  I cannot submit a bill to Medicare and the patient can’t either.

After finishing my explanation about our payment set up to George, I waited for him to make one of the rebuttals I that typically hear, which I’ve come to assume are based on the following train of thought:

•    Your practice costs too much …
•    I want to pay a $20 co-pay …
•    I want to get my money back …
•    Is this guy for real? …
•    Maybe he’s  one of those doctor-predators, who will rob me blind …
•    He must think he’s too special to accept insurance or Medicare — an elitist, so typical of a doctor!

Instead, George responded with another question: “How much would it cost if you removed the lesion at home?”

I told him that the cost would be about $375, including supplies. The biopsy report would be covered by Medicare.

Understandably, George wanted to discuss the matter with his mother and consider other options. I had no issues with George wanting to look elsewhere, but I wanted to be upfront with what we could offer him and his mom in comparison:

1. Our practice offers direct access to our doctors: We see patients the same day. Furthermore, when someone calls, a practitioner will answer the phone or call you right back directly. I suspected that George would spend the rest of the day trying to reach a doctor directly who accepted Medicare and could see her quickly –- the appointment probably would be made for several days later.

2. We treat fast: We could treat George’s mother that day, or he could take her to the ER, or to find another doctor who accepted Medicare and made a house call (of which there are few). Furthermore, if the nodule was a skin tumor and George went to the ER, they could do nothing and instruct him to see a dermatologist or regular doctor and send her home.

3. Our practice is cost-efficient: If George opted for an ER visit, he would need to enlist many people to help get his mom to the hospital. The ambulance bill alone is $500 to get her to the ER, and that does not include how he would get his mother home. Medicare may cover the ambulance.

4. We could save him time: The wait in the ER could be 4 hours or longer.

5. We would ensure easy follow up: If George’s mother had an infection, it would need to be drained, antibiotics administered and she’d need to follow up in a day or two with her regular doctor – who might not make house calls, so he’d need to figure out how he’d get his mom to the office. Or, if he took her straight to a dermatologist, he’d need to find someone who’d see his mom quickly and who would not make the issue a “two visit problem:” one visit or the consult and second visit for the removal (which doesn’t include the follow up).

George called me back within 20 minutes with a green light to come. Two hours later I arrived at his home and went to the bedside of his mother. She was a sharp-as-a-tack 84-year-old who could whip me at crossword puzzles any day of the week. Her knees were badly arthritic and she hadn’t been out of bed in months. Her forearm had a raised penny-sized  nodule that was tender and was not crusting or cratering. I suspected a keratoacanthoma and removed it and sewed it up at the bedside. Her biopsy confirmed my suspicion.

Mission accomplished for $375. George agreed to remove the stitches in 10 days, and my patient never needed to leave home.

Here was George’s email to the elder care manager who’d recommended that he call us:


Hi Laura,

Doctalker returned my call. Dr. Alan Dappen had an earlier cancellation. He arrived here by about 12:15 PM, and was able to address the problem.

Mother and I are very, very pleased. We now have an account with them … a wonderful recommendation!!

Thank you very much,



His mom has not needed any follow-up care and her arm bears no scar. I know this because George and I play tennis regularly now. He’s a great tennis partner, and the senior care manager deserves all the credit — she made a wonderful recommendation for me, too!

Until next week, I remain yours in primary care,

Alan Dappen, M.D.

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