Out of order to ask doctor to pay full attention during a visit?
January 2, 2017 5:34 PM   Subscribe

I was dx'd with Lupus back in 1989, had a wonderful old-school (by that I mean he was in his late 70s when I first saw him) rheumatologist at the time who was also an internist. Sadly he passed away in 2003 and I began seeing a rheumy in the practice recommended by deceased rheumatologist's office. Even though new rheumy is also an internist, in recent years he is becoming more "by the book". For example, as of 2014 his office required all patients to pay for their visits (whether co-pays or full price) prior to seeing him (instead of at the end of the visit). In late 2015 my employment situation changed so that I no longer had health insurance (I couldn't afford COBRA, which ran just over $1400/month). As a result, I ceased my twice annual appointments with rheumy, because I could not afford the office visit (he saw me once after my insurance ceased for the "discount" price of $90, but did not run any blood work) plus the lab fees.

I've been paying full price for my various prescriptions in the meantime, but as of now many of my refills are running out and the rheumy's office phoned me to say that they would not authorize any more refills until I came in for an appointment. I informed them that I was looking for an insurance plan (don't get me started on the headache that is for a neophyte used to previously being covered by an employer) and was told that they don't accept Medicaid or Obamacare (which I thought was not a specific plan, but nevertheless they repeated they don't accept Obamacare or HMOs).

Anyway, I need refills on my vital medications....Plaquenil, for one, which is the main drug used to treat Lupus. Now here's one of my questions/complaints: when I used to see Old School Rheumy, he routinely included an Anti-Nuclear Antibody blood test with my lab work at each visit. I was able to ask him "What's my ANA?" when I called for test results (and on the Lupus message boards I used to frequent, everyone knew their ANA, and once it got above a certain level their meds would be adjusted accordingly. I'm not a doctor, but after being a Lupus patient all these years I've learned that the ANA is the vital diagnostic tool when it comes to adjusting meds). I've asked New Rheumy a few times over the past few years "What's my AMA?" and he'd reply that he hadn't ordered that test, just a CBC. So, if he hasn't checked my ANA in many years, can he require me to come in and pay for a non-insured visit just to refill my Plaquenil (the dosage of which hasn't been changed since 1998)?

I guess, in response to my own question above, he can do whatever since he's the doctor, but here's Question Two: if I make an appointment and pay for the office visit and lab work out of pocket, would I be out of line to request that he not step out of the room to answer his cell phone (which he has regularly done during my previous, insurance-paid appointments over the years) and treat me personally, not hand me off to the resident/intern who is shadowiing him (another frequent occurrence)? I'm all for med students getting learning experience, and in the past I didn't complain that I had to spend most of my appointment repeating things that were on my chart and had been for over 20 years to a newbie who hadn't even yet decided that rheumatology would be his specialty. When I was only paying a $30 co-pay, I didn't mind so much that the rheumy was with me for maybe a total of 15 minutes during my entire appointment. But if I'm paying over $100, is it out of line to request that he personally attends to my entire appointment?

To summarize, if/when I make an out-of-pocket appointment, is it appropriate to request the doctor's full attention (presumably I'd have to make this request to the appointment-taker)? Or am I just leaving myself open to him deciding I'm too troublesome a patient and he'll wash his hands of me? If that happens, how do I get my Plaquenil refill? That's not really something I can go to an Urgent Care facility for, given the specialized blood test necessary (which usually has to be sent off-site).... or is it? It seems to me that any clinic would contact my rheumatologist for my records, and it would revert back to the "haven't had blood work done for over a year" conundrum.... I'm sorry, but this entire Catch-22 situation is just making my head spin!
posted by anonymous to Health & Fitness (12 answers total) 1 user marked this as a favorite
Is there a reason that you're not looking for a new doctor? This doctor doesn't take any insurance you can access, you don't like being seen by medical trainees, and you clearly don't like him and don't think he practices good medicine. Why don't you buy Obamacare and get a new doctor?
posted by i_am_a_fiesta at 5:44 PM on January 2, 2017 [48 favorites]

Yes, dtmf. Docs who don't listen are a waste of your energy, time and money. When you've got a doc who's on your wavelength, they can request your records from previous doc.
posted by anadem at 6:11 PM on January 2, 2017 [11 favorites]

If your state chose to participate in Obamacare there is likely a group that can have a person sit down with you and go through the marketplace plans and options and your needs (e.g. Covered California has health navigators, http://www.coveredca.com/get-help/) and get you signed up. This service is free, exactly because this stuff is confusing! If you can have a mod post your city/state or just state we can help you find one near you.

Call the doc's office and say you are in the process of getting insurance and are not sure you can go to this doc again, and will need 6 months of refills for your scripts so you can get new insurance and determine who you can see, and might end up on another doc's waiting list for a few months, and don't want to run out. If the doctor will not give you refills, or enough refills, call your pharmacy and talk to the pharmacist, explain your situation. They can let you know how bad it is to stop your drug(s) abruptly and if there are issues, can call and negotiate with the doc's office themselves to try to get you some refills on this account. Or they can help you learn how to taper down using the amounts you have left.

Go on Goodrx.com to look for cheaper prices on your drugs (they let you look by zip code). You can always have your pharmacist transfer refills to another pharmacy to take advantage of a lower price. There are also manufacturer coupons on Goodrx that I have used successfully in the past, but YMMV.

And the person on the phone was wrong, you are right- Obamacare is not a specific plan, but individuals buying insurance directly from the same companies that offer employer-purchased plans and expanding access to government insurance plans like Medicare. For the self-pay plans, it's some of the same companies and similar policies (coverage differences) as a company would offer employees.
posted by holyrood at 6:41 PM on January 2, 2017 [3 favorites]

The person on the phone might not have been wrong, just speaking in shorthand- doctors know which product lines and plans are available on the exchanges, and some choose to participate with none.
posted by ThePinkSuperhero at 6:51 PM on January 2, 2017 [1 favorite]

Many doctors will not prescribe for patients they haven't seen in over a year; it's a liability issue for them. I'd suggest seeing this doctor one more time to get your prescriptions up to date, then looking for health insurance and a doctor who will take your health insurance.
posted by lazuli at 8:02 PM on January 2, 2017 [9 favorites]

I would also say that Congress is working toward repealing the pre-existing conditions clauses of the Affordable Care Act, and is likely (from everything I've so far read) to put in place a system that will jack up insurance premiums for people with pre-existing medical conditions who have not maintained continuous insurance. Having a chronic health condition and not being insured right now is a really bad idea. I realize it's unavoidable for many, given premium costs, but if you can afford any sort of plan, even if it doesn't cover your current healthcare providers, it may be worth signing up during open enrollment to hedge against what's likely to come.
posted by lazuli at 8:06 PM on January 2, 2017 [6 favorites]

And open enrollment (which means you can enroll for any reason at all) for Obamacare/Affordable Care Act plans ends January 31, so I suggest you figure out something by the end of the month.
posted by lazuli at 10:04 PM on January 2, 2017 [2 favorites]

Seriously? I have never, in my entire life, ever, EVER had a doctor step out of an appointment with me to talk on a cell phone. That's really out of the norm.
posted by bq at 10:19 PM on January 2, 2017 [1 favorite]

Here are some ideas.

(1) Call up/contact/write local support groups/research organizations/bulletin boards that deal with Lupus, and ask for advice/tips for finding a low-cost/Obamacare-friendly practitioner in your area. They may also be able to help guide you to finding cheaper ways to get your medications. (See below.)

(2) Google the manufacturer of your medications. Some of them offer discounted or sometimes even free medications, depending on income. Different manufacturers have different forms to fill out, but some are extremely accessible. You will still need a prescription, but this could lower the cost of the medication significantly, if you're lucky.

(3) If the manufacturers of your meds don't have a discount program, do any of their competitors?

(4) Call your local council member, legislator, state senator, state congress rep (in that order, from low to high; keep calling till someone helps), and find out how they can help you: find a new doctor, insurance, and low-cost medications. Note that it's their job to help constituents, and whether you voted for them or not doesn't matter, so they won't ask. The issue is you could.

(5) If you don't think a doctor is doing their job properly, find another. Always. (And if you think they're really bad, consider lodging a complaint online or with an actual medical board. Walking out on appointments. Not taking insurance through a state exchange. Not answering questions. This is on the edge of unethical as far as I'm concerned, though I realize not everyone would agree.)

Good luck, and do this quickly. You'll be less stressed out once you understand your options better, and then act on them.
posted by Violet Blue at 11:11 PM on January 2, 2017 [3 favorites]

IAMAD, IANYD, and I am not a rheumatologist, etc etc

1. You should see a physician you like and trust, and you sound pretty disappointed in your current one. This is especially important for a rheumatologist, whom you'll having a multiple decade relationship with.

2. All rheumatologists are board certified in internal medicine. It's required as part of the qualifications for even starting rheumatology training. Relatively few rheumatologists practice primary care internal medicine separately from rheumatology in this day, although the nature of the field functionally tends to be primary care for autoimmune disease patients.

3. While a doctor answering their cell phone during an appointment is tasteless, occasionally a busy academic physician who is taking care of patients both in the office as well as patients admitted to the hospital will take urgent calls from the hospital to answer questions about hospital patients. This shouldn't be a regular thing, though.

4. ANA titers are typically a screening tool for autoimmune disease in general and aren't used to track lupus disease activity. Lupus severity over time is generally followed by evaluating clinical symptoms and other, non-ANA blood tests. ANA is one of the most common blood tests doctors order, however, and you can get it done anywhere, including urgent care, if you feel you need it. Note most urgent care physicians are emergency medicine trained and will not feel comfortable prescribing more than one refill for a chronic medication.

5. Regardless, any new doctor you see will almost certainly order a full panel of blood work for lupus evaluation just to cover their bases, so you don't need to worry about being trapped by not having recent blood work.
posted by demons in the base at 1:06 AM on January 3, 2017 [6 favorites]

Are you looking for a new job? If you're not, are you collecting disability? Social Security Disability? The reason I'm asking is that with a chronic condition like yours you should be eligible for S. S. Disability and, possibly, Medicare. These are programs for people like you who have a long work history, they're not "welfare". Look into these programs, you don't need the stress.
posted by mareli at 6:58 AM on January 3, 2017 [1 favorite]

Speaking as a doctor -

someone with a bad bedside manner and acting dismissively towards you is IME not likely to "shape up" because you asked nicely. I would look for a different doctor.

I personally do not trust doctors who act rude towards their patients. They may know their stuff but things like acting dismissively, leaving the room to talk on their cell phone without apologizing and explaining the situation, not addressing patient concerns - would make me worry that there might be other slip-ups in their care.

I'd look for someone who listens and who explains things. Seconding demons in the base about ANA titers not being used to track lupus activity. The thing is, a good rheumatologist would explain it to you, as well as the rationale for ordering CBC instead, instead of waving off your request.

Best of luck.
posted by M. at 10:49 AM on January 3, 2017 [3 favorites]

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