Pre-R’s Niche

Photo by Louis Maniquet on Unsplash

“Don’t get me wrong. The model you have made for Pre-R is awesome. I love it. My point was that the Pre-R model works for a certain set of clientele. I wish it would work for the larger healthcare system as a whole, but I fear that there are too many people who think they know more than you because of what they read on Google and therefore just want their Rx regardless.”

The author of this Facebook post is exactly right. Pre-R has its niche. Though I don’t mind people using Google. I’ll expand on that later.

In the US we’re essentially shoved into a variety of groups. Broadly, government based coverage has 6 subgroups. We have Medicare for the elderly, and Medicaid for folks with low income. Medicaid was massively expanded by the ACA, and is what helped to get coverage for a lot more people. It’s the interesting one in greatest flux these days. Other govt systems are the VA, Indian Health Services, Tricare for active military, and State Children’s Health Insurance Program (SCHIP).

We rarely get Pre-R calls from anyone with government based insurance. When we do, often they’re disappointed that we don’t take insurance. Most aren’t interested in a direct pay model even if our fees are relatively low. They want care both fast and free.

Unfortunately, however, I find that many with government based plans often have “spotty care.” They can visit walk-in clinics easily, but they may see a smattering of caregivers. Some sense that they’re falling through the cracks, which sometimes leads them to me in ERs where all cracks point.

For these patients in ERs, medical records are often extremely hard to dig up. And because followup can be so variable, we in ERs frequently over order tests and treatments. Patients with chronic headaches or belly pain may receive multiple CTs at multiple hospitals. We try to control ourselves, but no ER doc wants to be the the last in line to miss something. On top of that, because patients with these types of insurance aren’t paying much (if any) of the tab, they’re usually game for consecutive massive workups, “just to be sure.”

On the flip side, some patients with government based insurance really do love their coverage, and they’re happy to visit ERs for anything at all. On my last shift a woman brought in her otherwise happy baby at 11pm because of a darkish colored tongue. I’m pretty sure she faced no copay. Some patients will come requesting Tylenol prescriptions. Others want simple work notes. They’re certainly not fretting over $1000 ER bills. Pre-R really offers them no value. (And because of EMTALA anyone can be seen in any ER whenever.)

As for treatments, I find that people with government based coverage often have enormous meds lists too. I suspect this is because time is limited in caring for them in clinics and ERs, so it’s often easier to reach for the prescription pad than to have long conversations followed by multiple follow up calls. Because of their coverage, few ask how much the prescriptions may cost either. I suspect many still get sticker shock in pharmacies though, which may lead to “noncompliance.”

So for government covered patients, their personal costs may be low, but the care can sometimes be suboptimal. (If you work for the VA or IHS or similar, please don’t shoot me or feel accused. The point is that free does not mean better. The other point is to be careful what you wish for with “universal healthcare.”)

You may want to read also Universal Healthcare? Please define

On the other end of the spectrum are the absurdly rich. These are people who snap their fingers to receive antibiotics, sedatives, narcotics, surgeries, etc. They may pay top dollar to be members of concierge medicine practices, or they may have 1:1 personal physicians at their beckon call. This kind of medicine is the basis for the show “Royal Pains.” Sometimes people compare Pre-R with the show, but we’re really nothing close.

These patients benefit from and enjoy super rapid service, with no waiting room hassles and risks. They don’t bicker with insurance companies, because no need. (I doubt Bill Gates has Anthem Blue Cross or Blue Shield.) Unfortunately, they also occasionally get killed by propofol drips at home (think Michael Jackson).

I rarely get calls from ultra rich people, I suspect because they’re generally already dialed in. Well off patients who call who don’t want long conversations about the risks and benefits of antibiotic, sedative and narcotic overuse don’t seem to call twice.

In short, being rich carries its risks too. I sometimes wonder what path Steve Jobs would have followed if his finances had been a little tighter. Actually, probably the same… Stubborn, brilliant guy with a stubborn, awful disease.

Pre-R has a pretty specific clientele. Our patients are cost conscious. They often have high deductibles and high copays. (Vanessa and I fit in this group too.) Sometimes our patients have rejected the ACA mandate and have no insurance at all.

Our patients love Dr. Google and I love that they do. Sometimes I learn from patients that way too. Periodically they discover meds I’ve never heard of and I’m forced to go reading. They’re usually pretty happy about our fees, and sometimes they’ll donate to us for just an uninterrupted conversation on the phone placed from wherever.

Uniformly they are angry at the US medical system, because they’ve watched their premiums rise, as their doctors have abandoned private practices, while clinic, hospital and prescription costs have soared in parallel. Some of our patients are prodding the GOP to repeal and or replace the ACA, and I really can’t blame them. Unfortunately, however, I suspect whatever emerges will result in higher premiums and even worse care. Do you really think BC/BS and other insurers will ever rewind to 2007 prices?

The good news for this group is they’re getting smarter and more savvy. They (we) question everything. “Why exactly do you need to check my vital signs for an ankle sprain?” “Did I seriously get charged $50 when they put that oxygen sensor on my finger?” “Does this Epipen truly expire in 12 months?”

Pre-R isn’t the answer for US healthcare. We’re just filling gaps. Neither is the ACA, nor I suspect whatever the Senate is currently churning. Universal healthcare also to me is an illusion. Maybe some country could do it, but not this team. As long as lifespans continue to lengthen, and end of life care remains lucrative, our capacity to invent disease names, diagnoses and treatments will keep us monetizing and capitalizing on suffering indefinitely, with prices pointing forever skyward.

I’ve posted other proposals here in the past, but they were quickly buried by competing noise. That’s life today. If you’ve read this far, first off, thanks! And my recommendation for everyone both inside and outside the healthcare bubble is to research and question every medical recommendation you receive. “Do I really need this?” is my mantra.

Pre-R is not an answer for everyone, and it’s definitely not the answer for US healthcare. But it’s my way of helping one slice of the public without feeling chronically malcontent as a cog in a gross system.

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