Saturday, March 28, 2015

Why copayments for medical appointments are a bad idea: a breast lump story

When conducting a routine breast exam during my annual physical, my doctor detected something on the armpit side of my left breast that wasn't present on the right side.  He ordered a breast ultrasound, which found some of my  lymph nodes in that area were larger than perhaps they should be.  A mammogram was then ordered, which found that a few individual lymph nodes were enlarged, but there were no malignancies or other problems.  I was therefore instructed to return in six months for another breast ultrasound to see if the lymph nodes in question returned to normal.

While I was in the middle of this process, Steve Paikin posted a blog post sharing his doctor's idea for copayments for each medical appointment.  I commented on that post expressing my concern that the majority of medical appointments I get aren't even my idea but rather are required by red tape (I've previously blogged about that here), but this breast lump diagnosis process was an even better example.


During this little adventure, I had five appointments in a nine-day period (and a minimum of three more if I opt to follow up in six months as recommended), none of which I actually wanted or would have thought to request for myself.

I only got the annual physical because it's the price of admission for getting my birth control renewed. I'd be more than happy to buy my birth control over the counter (as some have recommended should be possible for public health purposes), but I have no choice but to go to my doctor and get the recommended screenings if I want a new prescription.

I didn't think the thing my doctor found was a problem - to my touch it felt just like a normal part of my breast anatomy. After reading up on breast cysts, I didn't think getting a potential breast cyst diagnosed was especially important - they're not a problem, most often non-actionable, and quite often go away by themselves. That area of my breast is squishy and mobile, it's nothing like the description of hard, immoveable lumps that I've always been told indicate possible cancer.  But I went along because it's a quick, easy, non-intrusive test and it was probably faster to get the test than to argue.  And, I figured, once the test shows it's nothing, my doctor will be more likely in the future to take me at my word when I say that's just how my breast is.

After the test, I had to go to the doctor for test results, which I think is a suboptimal way of doing things. I'd rather have the results emailed directly to me, and schedule an appointment with the doctor if I had any questions. But my doctor's policy is that they only contact you with results if action is required, so if I didn't go for that follow-up I'd never learn what action was apparently required.

On an intellectual level, I didn't think the mammogram was necessary as a follow-up to the ultrasound either.  After reading up on breast ultrasounds, I didn't see why a mammogram would be helpful or informative as a follow-up to an ultrasound - all the information I found talked about how ultrasounds saw things that mammograms didn't see.  But, frankly, I was scared into it.  Getting a phone call telling me I needed a mammogram (when this wasn't on my "things that might happen" list) was shocking and disconcerting.  I have it mentally categorized as a "cancer test", so it triggered fears of cancer, and I went along with the test to rule out cancer.

And, again, I had to go to the doctor for the mammogram results even though they were clear to me and I didn't need any help with interpretation.  Because I have no way of getting the results without going to the doctor, I had to take that appointment or I would never have received confirmation that there were no malignancies.

So that's five appointments, all of which were required by my doctor as opposed to by me, none of which I would ever have asked for myself if it were completely up to me.  And if I follow up in six months, I'll need three more (one with my doctor to get the ultrasound requisition, one at the imaging clinic for the ultrasound, and one with  my doctor for the ultrasound results.)  I'm really disinclined to follow up - it feels like a fishing expedition - but I'm concerned about being considered a non-compliant patient if I don't, and I do need my doctor's goodwill to keep getting my contraception.


At this point, some of you are thinking "Breast lumps are serious business!  It's good and important that you got it checked out - you really shouldn't skimp on that sort of thing!"

If that's the case, that's a very good reason why there shouldn't be a copay for each appointment.  A copay would disincentivize patients like me from following up on lumps in their breasts, or perhaps even having these lumps detected in the first place.


Besides all that, before they can even consider a copay, they'd have to streamline the process so that fewer appointments are required by red tape.  For example, as I mentioned above, they shouldn't make you go in to see the doctor to get your test results.  It would be much more efficient to just email them to the patient when emailing them to the doctor, and the patient can contact the doctor if they have any question.  When I'm doing medical translations, I find it a fairly simple matter to google up any terminology I don't understand and the implications of the test results become apparent once I've worked out the meaning of all the words.  If they want to cut down on the number of appointments, they need to at least start by eliminating unnecessary appointments like test results that can just be replaced by a simple email!


At this point, some of you are thinking "That would be hideously irresponsible!  Many people can't accurately interpret medical results and there's all kinds of ridiculous information on the internet! People who aren't medical professionals need the guidance of medical professionals."

If that's the case, that's another very good reason why there shouldn't be a copay for each appointment. A copay would disincentivize patients like me from discussing our test results with our doctors, and instead leave us making decision based on our haphazard informal education and Google.

3 comments:

laura k said...

I'm sorry you had to go through this. I wonder if this was the true source of the stress you've mentioned in previous posts.

On the topic, you are 100% correct about copays! They are both a bad idea and a slippery slope towards a fee-for-service system. And once we're fee-for-service, we've lost universal health care. (Which we know is not truly universal, but leaving that aside for now.)

impudent strumpet said...

Oh no, this was a whole new and exciting source of stress. It all happened in the past week, long after the various other stressers happened/began.

I was very fortunate that all the turnarounds were far faster than usual, so the whole thing was confined to a single week. At their normal target turnaround times and wait times, it would have taken at least two.

laura k said...

Stress added on top of stress. Ugh.