I first saw Mr. Smith (not his real name) in April of 1997 regarding severe problems with arthritis and prolonged morning stiffness. He told me that his feet hurt so badly that he felt as if he had spikes going through them. His rheumatoid factor was weakly positive. Because Mr. Smith was extremely uncomfortable at his first visit, I put him on prednisone, and I had him come back a week later for a follow-up visit. I started him on methotrexate. His rheumatoid arthritis (RA) improved nicely, and over the next few months, he was able to taper off his prednisone.
Mr. Smith continued to do well over the next 15 years. He was pleased with his progress, and I had the satisfaction of watching his improvement. This satisfactory arrangement might have continued until retirement, or death do us part, except for one small hitch.
Office copayments are on the rise. I know this because my office jots this amount on the patient’s superbill. Five or ten dollar copayments are a thing of the past, and copayments ranging from $30 to $45, and sometimes as high as $60, are common these days. Patients vote with their feet when the costs of their visits become exorbitant. My nurse sent me the following note regarding Mr. Smith via our electronic medical records system:
Spoke with patient. He has seen Dr. Greenbaum for RA. He sees Dr. Blank (not his real name) for primary care. Patient has to pay $45 copay with Dr. Greenbaum and zero copay for Dr. Blank. Can Dr. Blank take over filling his prescriptions for RA? This will save him money.
Dr. Blank is a bright young internist in my group, and I knew he was quite capable of refilling Mr. Smith’s methotrexate and monitoring his labs, so I sadly typed back my acquiescence for the transfer of Mr. Smith’s care. I certainly couldn’t blame Mr. Smith. Why would he want to waste $45, several times a year, if his arthritis was doing well? In addition, patients hate having multiple doctors. Even in the best-case scenario, it’s confusing, expensive, and time consuming. In addition, patients have good reason to worry more about medication interactions when there are multiple prescribers involved. Long ago, in my training years, a patient at the VA told me that I was one of his favorite doctors. I was flattered to hear this, but after he mentioned that he had six different doctors, I began to wonder if this was really an optimal way to care for patients.
My patients frequently try to cajole me to assume some or all of their primary care. This line of wheedling sounds something like, "Gee doc, couldn’t you just refill my blood pressure medication? It will save me the time and expense of having to make an appointment to see my primary care provider (PCP) just to get refills on my medication." Sometimes I cave into these blandishments and sometimes I don’t. Undoubtedly, the same scenario occurs in the PCP’s office. Many of my patients are probably asking their PCP to refill their arthritis medications so they don’t have to go to the trouble and expense of seeing me, effectively transferring some or all of their arthritis care to their PCP. This type of behind-the-scenes attrition is more subtle than Mr. Smith’s explicit request to save $45, but probably is very common. The higher the office copayment, the more economic incentive patients have to streamline their care. Patients love having one doctor in charge of everything, and who can blame them?
Insurers have enshrined the notion that PCPs are good for their bottom line, but specialists are driving up the high cost of health care. Of course, there are some caveats regarding this health care strategy. The desired cost savings of having the PCP assume the role of the specialist is not always feasible. Over the years, I’ve seen some PCPs put their patients on a masterful combination of RA medications. The treatment plan of those patients read just like a medical textbook chapter, but they weren’t doing well because they didn’t have RA. Don’t get me wrong, rheumatologists make mistakes, too, but some of these patients were on corticosteroids unnecessarily for years, and some are never able to taper off entirely. Sometimes a transfer of care is appropriate, and sometimes it isn’t. Perhaps in the near future, the rheumatologist’s role will be quite circumscribed. We’ll make a diagnosis, initiate treatment, and send the patient back to the PCP with just occasional input from us. This consultative approach will work for patients that are doing well, but not for sicker or more complicated patients. Some patients will have to pay higher office copayments, but others might get off cheap.