Re: Another great moment:

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Maybe Oregonian urgent care docs would have sent her home home with iron but not this Virginian. 72 yo, hct of 26, hx of unknown primary liver mets, hx of radiation, and RUQ tenderness, plus she avoids doctors. My spidey senses are tingling. I would have sent her to the ER immediately. My employer would have made money on the cbc and ua and I may have charged her a 22902, but more than likely I wouldn't have charged her at all (this may be a luxury you don't have being an imp) because I was only pointing her in the right direction and knowing she would be getting financially drained at the ER. StrazFrom Oregon, Here is an example of the inequitable payment system we have: I have a Mrs E, who is a 72 year young person who had some unknown cancer twenty years ago in her liver, and had been treated with surgery and radiation, and had decided she was done with doctors after that. She developed diabetes mellitus after the treatments, but it was mild, stable, managed with an ancient first generation oral medication which she never wanted changed, for which she came in one time a year for refills. She never wanted to have "health maintenance" done, and it was all I could do to get her to let me do one annual blood test which she submitted to solely because she liked me. Last Thanksgiving she came in for her annual exam and blood test and again she had untreated hypertension which had been creeping up on her...now it was 190/95. Okey, she now let me start her on hypertensive medications because she didn't want to become disabled with a stroke. I donated $20.00 to her Turkey Fund for the Poor, and asked her to please come back for another test to be sure the new meds were safe for her. Three phone calls later, and three months later she returned for the blood tests, reluctantly, and said she thought the blood pressure meds didn't agree with her. The blood test results showed that her HCT was now at 26.3 down from 33.9. I called her for an appointment which she missed because she wasn't feeling well; I called her daughter, who brought her in, and they asked to stop the blood pressure medication, because she was so tired. I let them know that her blood pressure remained a little high, not low, and that it was likely that the weakness was from the anemia. It took some time to elicit the information that Mrs E had been getting faint upper right GI pains behind her liver, which she thought was from her old scar. I called a gastroenterologist to alert him she was coming to the ER, because I thought she probable had an ascending colon cancer. I called the ER to alert them she was coming in and might need a blood transfusion. I wrote a history and physical for that days visit using my EMR and documenting my assessments, and sent that along with her lab tests from the last week and three months previous documenting the dramatic decrease in blood values. She was driven by her daughter into the ER, was in a hospital room with an IV blood drip in two hours, was given her ultrasound (I had suggested the untrasounds after documenting Mrs E's iodine allergy) the next morning and in 48 hours she had her ascending colon and all the associated lymph nodes removed. Three of the 25 lymph nodes had a few cancer cells in them. I called on her in the hospital and she thanked me for saving her life. So did her daughter. I felt good too, because it is a tricky call. But you have to look at the reimbursment: Payments: Hospital nearly 15000 including imagry and extras Surgeon around 5000 after all the followup Admitting Gastroenterologist $800 for admit and some days dropping into the room (he copied my note with some extra big words) My pay from Medicare: $75,00 just came this week. If she had gone to an urgent care MD who did not know her, he would have likely have stopped her lisinopril, given her some Iron, and had her return somewhere... and be paid more for it because he was Urgent Care. Anyone want to know why senior medical students chose to become specialists? Who would anyone want to be in this scenario...the $75.00 MD or the $800 MD or the $5000.00 MD? They don't pay for phone calls to patient, daughter, ER, GI specialist, most coordination of care, immediate production of a useful H & P, or the extra time talking to the patient about her fears, or the donation to the Turkey Fund. Well, I wouldn't want to be reimbursed for the last thing. And I do understand I could come up with some extra...what, maybe $18.00 or so.. for some care coordination. My point is that, this is a crazy varience in reimbursement considering the value of our services. Joanne Holland, Old MD in Drain, OregonBe a better friend, newshound, and know-it-all with Yahoo! Mobile. Try it now.