Group of medical workers portrait in hospital

A few weeks ago, I taped the first episode of my new public radio show. I thought I sounded pretty good, and the producer assured me that I would sound even better after I got over my cold. This would have been assuring, except that I didn’t have a cold. Fearful of being fired my first day on the job, I immediately called my primary care physician (PCP) to get some advice on how to sound less hoarse and nasal. The PCP’s office promptly scheduled a visit with an ENT, only four days later.

In twelve short minutes, this visit encapsulized everything that is wrong with fee-for-service medicine. The ENT scoped my nose and announced that I had polyps in my sinuses. She said she would schedule me for a CT scan of the sinuses, and offered three alternative treatments, which, she added, may or may not work.

  1. Steroid-based nasal spray
  2. Steroid-based nasal spray with a three-week course of antibiotics
  3. Day surgery followed by a saline flush for a week.

“So,” she asked, about seven minutes into the appointment, “which do you want to do?”

“Um,” I replied. “Shouldn’t we try the most conservative therapy first?”

“Well, you could.”

I begged off that one by quite correctly observing that I wasn’t very adept at flushing my nose out, so that I would prefer one of the non-surgical alternatives. “I’m not sure I need the antibiotics because I don’t think this is bacterial,” I said.

“A lot of patients report relief with the antibiotics,” she replied.

“Isn’t three weeks a long time to be taking antibiotics?” I asked.

“Yes. Some people say that.”

I opted for the nasal spray. I elected not to schedule the sinus CT scan. Seemed like a lot of cost and inconvenience…and didn’t I just get a diagnosis anyway?1 So I didn’t ask for it. Except that the sinus scan was thoughtfully scheduled for me, as I learned when a scheduler called me the same day. I ignored my first call from the scheduler, but after the third, I realized they really did expect me to show up (that very Friday, no less), and it occurred to me I might get billed unless I affirmatively called to cancel it.



And, that is what is wrong with fee-for-service medicine. Most well-insured people would have gone along with the recommended program, getting the scan, the surgery, and who knows what else. That’s why large physician practices need to be at partial- or full-risk, to discourage overutilization, and why we need patient-centered medical homes to prevent over-referring to specialists, and why electronic medical records with checks-and-balances built right into them will be helpful in avoiding unnecessary care.

Except that this practice has used an EMR and been fully capitated for more than a decade now, and is already a designated patient-centered medical home.

That is the “punchline,” and explaining a joke often ruins it, but healthcare isn’t a joke so I’ll explain. Just changing practice incentives may not change the behavior of individual physicians, especially specialists who even in most capitated practices are/will still be paid on the basis of work performed, to a large degree. Further, member satisfaction also factors into compensation, and what can be more satisfying than promptness and responsiveness?

And the EMR? The EMR is what expedited the referral in the first place. Years ago, it had been noted that I had a deviated septum (like about half the world, as it turns out). That information was duly stored in my EMR, so that my PCP had grounds to make a referral at her fingertips, without needing me to see her first.


The coda on this story?

The coda on this story? To try to overcome this hoarseness, I took the steroidal nasal spray twice a day for a week. Then I read the FDA insert, which listed as a side effect: hoarseness. I stopped the spray, and told this story to my producer. My producer suggested tea with honey during each taping, surely the most conservative therapy…and I still have my job. So domestic policy wonks in the Washington DC market can now hear me on The Big Fix Saturdays at 4 PM on WAMU 88.5. I’m still a bit hoarse, but thanks to my producer, I no longer sound like that guy on Boardwalk Empire whose vocal chords were blown up during World War I.

1 *I suspect one reason a lot of scans get done is, that word “scan” is very comforting to most people because it sounds painless and benign, but in reality it involves a ton of radiation, not to mention contrast media they don’t bother to tell you about until you already have your gown on.  If physicians were to replace the words “scan” with a more picturesque term, scans would become much less popular.  (Ask the GOP how to do this.  They coin terms like “death tax” and “partial-birth abortion” all the time.)   In this case I might propose that a physician who wants to order a sinus scan be required to say:  “I would recommend 500 curies of radiation be directed at your head and that blue dye be introduced into your veins that might damage your kidneys and leave a metallic taste in your mouth.”

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  1. More and more I am hearing anecdotal stories from employers who are empowering health plan members to be more informed consumer that individuals are not only saying NO, but they are firing their doctors because of misdirected or inappropriate care. One client just shared with me that a diabetic member had fired their endocrinologist because they refused to check their A1c more than once a year AND would not share lab results with their pharmacist-coach. The client was thrilled with the ownership/accountability this member had demonstrated.
    Personally, I have twice said NO to a doctor in terms of what they prescribed. One time was when they prescribed a cardiac drug for my arrhythmia (can no longer remember why they wanted to change up my treatment). I dutiful took my prescription, got it filled, only to get home, read the insert, which cited for drug safety a mere 300 life study where sudden death was was the worse outcome. I never took the drug, called my cardiologist back and asked for a less potentially toxic treatment course, which turned out to be the same generic drug I had been on for 10 years, and continue on today – with absolutely no side effects and very effective management.

  2. Al,
    I’ve just come across you from LinkedIn and I must admit I’m intrigued by your knowledge and the way you put things together. I’m interested in investigating what you have to say and analyzing if it makes sense to me in the operational world, i.e. how things work in the day to day of healthcare. Re: your post above about “what’s wrong with fee for service”, I don’t find myself in disagreement. It seems like a lot of expense for your complaint. As an older RN married to a PCP/MD/FP my perspective on your complaint is that someone should be following you for a bit, (3 mos?) to consider if your hoarseness might be something else. However, the trend in care seems to be the squeaky wheel, so if you don’t return to either MD to offer your complaint then it probably won’t be followed. Personally, I’m happy your encounter is doc’ed in an EMR, as if the complaint does become significant in the future, the providers at the time will be able to see it there (I hope! What is the expected holding time for EMR’s info? 7-10yrs?) I like your idea of conservative first, get info from that behavior and go forward. Seems it should always be that way. What part of first line docs being overworked and overwhelmed might get them to refer you on and on just to get you off their schedule? Even if some part of that wondering is true, it doesn’t help the cost of healthcare in any way, but might, as you point out, work towards patient satisfaction. I’m all for the patient feeling satisfied, but that often doesn’t happen in health care, since my diagnosis may be life threatening and that doesn’t usually make anyone feel good. So maybe one big item to work towards equalizing in this healthcare mess is patient satisfaction vs. disease management and cost containment. I am totally in the corner of getting rid of fee for service. It’s major effect has been to bloat the industry all through the chain, including hospitals, privately owned clinics and specialty services.

  3. Thank you, Cindy, I do “feel better” mostly because I was never sick. And I am hoping that you are successful in your mission to get more outcomes-based pricing, though the irony is that these folks were already supposed to be getting compensation that way.

    And while a few people complained about my hosting skills to WAMU, no one said: “He sounds like he has polyps in his sinuses.”

  4. Well done, Al! You have illuminated the exact reason tha “evidence-based guidelines” can be conflicting and confusing. Plu, physicians may say they must offer all alternatives because of threat of lawsuit. Add in the FFS augment platform and the move toshkent patients more responsible, thereby presenting all possibilities, andante will choose the more complicated, thinking they will get better care. Paying for outcomes, including management/improvement of condition, but also sequenced complexity ( a risk and cost strategy), safety and satisfaction, makes more sense. PS I do hope you feel better.

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