Tales From the American Medical System

In a game where some actors are humans, we should expect the highest stakes at play to sometimes be lost. Or do you think that nuclear war is impossible these days?

I don’t think it’s necessarily greed.

Your doctor may be on a system where they are responsible for doing work for you (e.g. refilling your prescriptions, doing whatever insurance paperwork it takes to make your prescriptions go through, keeping track of when you need to get certain tests, etc) without receiving any compensation except when you come in for office visits. One patient like this isn’t so bad. Half your caseload like this means potentially hours of unpaid labor every day. Even if an individual doctor is willing to do this, high-level decision-makers like clinics and hospitals will realize this is a bad deal, make policies to avoid it, and pressure individual doctors to conform to the policies.

Also, your doctor remains very legally liable for anything bad that happens to you while you’re technically under their care, even if you never see them. If you’re very confused and injecting your insulin into your toenails every day, and then you get hyperglycemic, and your doctor never catches this because you never come into the office, you could sue them. So first of all, that means they’re carrying a legal risk for a patient they’re not getting any money from. And second of all, at the trial, your lawyer will ask “How often did you see so-and-so?” and the doctor will say “I haven’t seen them in years, I just kept refilling their prescription without asking any questions because they sent me an email saying I should”. And then they will lose, because being seen every three months is standard of care. Again, even if an individual doctor is overly altruistic and willing to accept this risk, high-level savvier entities like clinics and hospitals will institute and enforce policies against it. The clinic I work at automatically closes your chart and sends you a letter saying you are no longer our patient if you haven't seen us in X months (I can't remember what X is off the top of my head). This sounds harsh, but if we didn't do it, then if you ever got sick after having seen us even once, it would legally be our fault. Every lawyer in the world agrees you should do this, it's not some particular doctor being a jerk.

Also, a lot of people really do need scheduled appointments. You would be shocked how many people get much worse, are on death’s door, and I only see them when their scheduled three-monthly appointment rolls around, and I ask them “Why didn’t you come in earlier?!” and they just say something like they didn’t want to bother me, or didn’t realize it was so bad, or some other excuse I can’t possibly fathom (to be fair, many of these people are depressed or psychotic). This real medical necessity meshes with (more cynically provides a fig leaf for, but it's not a fake fig leaf) the financial and legal necessity.

I’m not trying to justify what your doctor did to you. If it were me, I would have refilled your insulin, then sent you a message saying in the future I needed to see you every three months. But I’ve seen patients try to get out of this. They’ll wait until the last possible moment, then send an email saying “I am out of my life-saving medication, you must refill now!” If I send a message saying we should have an appointment on the books before I fill it, they’ll pretend they didn’t see that and just resend “I need my life-saving medication now!” If my receptionist tries to call, they’ll hang up. At some point I start feeling like I’m being held hostage. I really only have one patient who is definitely doing this, but it’s enough that I can understand why some doctors don’t want to have to have this fight and institute a stricter “no refill until appointment is on the books” policy.

I do think there are problems with the system, but they’re more like:

- A legal system that keeps all doctors perpetually afraid of malpractice if they’re not doing this (but what is the alternative?)

- An insurance system that doesn’t let doctors get money except through appointments. If the doctor just charged you a flat fee per year for being their patient, that would remove the financial aspect of the problem. Some concierge doctors do this, but insurances don’t work that way (but insurances are pretty savvy, are they afraid doctors would cheat?)

- The whole idea that you can’t access life-saving medication until an official gives you permission (but what would be the effects of making potentially dangerous medications freely available?)

Grrrrrrrrrrrrr!!!!!!!!!!!

I thought that was a possibility but I didn't think it was too likely.

Don't they have enough money already? I've always been confused about people who are already extremely wealthy acting so greedily. Eg. CEOs. You already have a ton of money, the extra money can't mean that much to you because of diminishing marginal utility stuff, why hurt other people in pursuit of more? Is it that they compare themselves to others around them and want to have more than their friends? Is the pursuit of more just a habit?

What happens if you let patients buy refills without a prescription? Would they consume too much of it?

No. Prescriptions don't specify precise dosages, because those are adjusted much too frequently for direct doctor involvement.

Would there be any sort of risk of them selling the excess to others?

No. There is no secondary market for insulin, because primary-market insulin is easily available at the price of a plane ticket, and improperly stored insulin is unsafe and indistinguishable. Furthermore, no one is trying to restrict access (other than as a way to extract money).

Is there a medical reason why the doctor might not prescribe more insulin if he examines the patient and finds something new?

No. Type 1 diabetics continue to require insulin 100% of the time, no exceptions.

On that note, I wonder if the doctor is coming from a place of worrying about covering his ass and getting sued if he prescribes more insulin without the exam.

In fact, by refusing to prescribe, this doctor created a considerable risk. If the person in the story hadn't managed to get a prescription, and had died, a malpractice lawsuit would probably succeed.

You probably wouldn't want both the drug delivery and the diagnosis part to happen on the same website. You likely want the diagnostics to be hosted in a jurisdiction like Ecuador or maybe India, that needs cheap diagnostics and doesn't want to shut you down.

Alternative view: Your friend has a deadly disease that requires regular doctor visits and prescriptions. It sucks. It's not fair, but it requires him to take some level of responsibility for his own care. He seems to have failed to do so by not keeping his appointments and letting his prescriptions run out.

Type 1 diabetic here. Regular doctor visits are actually pretty useless to us, other than refilling the prescriptions. Every six months is customary, but excessive. Every three months is scamming money out of insurers.

Regarding the price of medicine in Canada: I believe the fixed low prices in Canada are being subsidized by your friend and all Americans.

It's cheap literally everywhere except the United States. It's not a matter of subsidized capital costs, because those were all paid off more than a decade ago, and prices were cheaper then.

Measurement every 3 months in patients with type 1 diabetes determines whether glycemic targets have been reached and maintained.

Measuring HbA1c can be done cheaply with an over-the-counter test kit. It does not require a doctor visit. Also, testing HbA1c that frequently isn't important and isn't done by most diabetics.

Your friend has a deadly disease that requires regular doctor visits and prescriptions.

I think that this is a sketchy way to phrase this. Presumably, what a disease requires is a cure (or one of several cures). 'Doctor visits' and 'prescriptions' are one system society can have to assign cures to people, but there could also be other systems, like 'you get to walk to a store and buy insulin if you want some without needing anybody's seal of approval, and you can also see somebody to advise you on how much insulin to take'. Saying that the disease requires regular doctor visits and prescriptions seems to me to rhetorically imply that the costs associated with those are due to the disease, not due to the health care system, without doing the work of checking how well the system works (after all, if the system were about as well as we could manage, the costs really would be due to the disease).

I am confused why anyone would believe that this post is attempting to pass an ITT. It isn't.

It's also giving the doctor the benefit of the doubt in important ways that jimrandomh seems confident are unlikely to be accurate - in particular, that the doctor's justification for such frequent and copious appointments is concern for the patient, and has no profit/fraud motive of any kind.

I'm really surprised this is being downvoted so much.

As far as I can tell (and frankly I don't care enough to put serious effort towards finding more information, but I do note nobody in the comments started with "I am a doctor" or "After talking about this with my own doctor, ...") OP's friend was in a life-threatening situation, the solution to which is a renewed insulin prescription. On top of that, the doctor/medical establishment enforces the rule that people (only young people? only people who recently developed diabetes? There could be a good medical reason here, I don't know) with Type I Diabetes have regular checkups.

Now I imagine there are all sorts of reasons for wanting to skip this checkup. Maybe the checkup isn't needed, and is just a money scam (small aside: if my doctor tells me I need a regular checkup, this is not my first thought. But individual situations can vary). Maybe the doctor's schedule is so unreasonable that it's impossible to make an appointment. There could be thousands of valid reasons. The problem as I see it is that, from the point of view of both the doctor and the nurse, they are only negotiating over the checkup. You mention right at the start that the nurse offered a solution ("drop everything and come see your doctor tomorrow") - from that point on the situation was no longer life-threatening! There was no realistic scenario in which this would cost your friend more than the plans they made for the next day! You were just haggling over what is more important, your friend's schedule or the rules set by the medical establishment that you need an active prescription to get insulin and you need a checkup to renew your prescription. Guess which one the nurse is going to find more important.

I understand if it feels like your friend is being blackmailed by the doctor (and in fact it seems like they are), but by refusing to visit the next day you are the ones who escalated the situation. And then escalated even further by threatening with media exposure. I think from the point of view of the nurse your friend is showing rather hostile behaviour. I'll take the liberty of going through the phone call as you posted it, filling in how I expect nurses to act:

The nurse tells my friend he needs to go see his doctor, because it has been seven months, and the doctor feels he should see his doctor every three.

Probably standard procedure. At any rate this decision it out of the nurse's hands, so they are just providing information here.

My friend replies that he agrees he should see his doctor, and he has made an appointment in a few weeks when he has the time to do that.

The nurse says that he can’t get his prescription refilled until he sees the doctor.

Still standard. Nurses don't get to overrule conditions doctors set for medication, if the doctor says a checkup is needed then the nurse has no way of handing over insulin.

My friend explains that he does not have the time to drop what he is doing and see the doctor the next day. That he is happy to see the doctor in a few weeks. But that until then, he requires insulin to live.

The nurse says that he can’t get his prescription refilled until he sees the doctor. That if he wants it earlier he can find another doctor.

Still the same issue. The nurse doesn't have the authority to overrule the conditions set by the doctor. Also I'm missing a sentence here, who introduced talking to the doctor the very next day?

My friend explains again that he does not have the time to see any doctor the next day, nor can one find a doctor on one day’s notice in reasonable fashion. And that he has already made an appointment, and needs insulin to live. And would like to speak with the doctor.

The nurse refuses to get the prescription filled. The nurse does not offer to let him speak to the doctor, and says that he can either wait, make an appointment for the next day, or find a new doctor.

So apparently making an appointment one a one-day notice is very doable on the doctor's side. By this point you are solidly haggling about time, not medicine. I also think the nurse could have let you speak with the doctor here. But I think it's also plausible that they get/did in the past get phone calls from all kinds of entitled weirdos who refuse to show up to appointments, and at this moment it's really not clear your friend is not one of them. Why would their day plans be more important?

My friend points out that without insulin, he will die. He asks if the nurse wants him to die. Or what the nurse suggests he do instead, rather than die.

This seems not to get through to the nurse, because my friend asks these questions several times. The nurse does not offer to refill the prescription, or let my friend talk to the doctor.

My friend says that if the doctor does not give him access to life saving medicine and instead leaves him to die, he will post about it on social media.

The nurse now decides, for the first time in the conversation, that my friend should perhaps talk to his doctor.

Really? Your friend escalates from "I don't want to visit you tomorrow" to "that means you must want me to die", which of course the sensible nurse ignores, and your strategy was to repeat it a few more times? Yeah, you really showed them there. I bet the nurse immediately realised they were wrong the first time, and connected you through with the doctor before you got to the third repetition. From their point of view you've refused a good solution to the problem and are now just bugging them to make your life easier (who likes going to checkups? Nobody. So who haggles about not wanting to show up? Well, not everybody, but more than just your friend I bet). And at that point your strategy is to escalate even more by threatening media exposure, and put even more pressure on that poor nurse? I'm not surprised the doctor claimed you are blackmailing them after this.

What was your goal of the conversation with the nurse in the first place? You need a doctor's prescription for the insulin, so shouldn't you have aimed for talking with the doctor? And if that was your goal, what purpose did it serve to tighten the screws on the nurse? You should have acted like a model patient and calmly requested you speak with the doctor, who can (and did) overrule the normal medical process just to give you life-saving medicine.

I guess that became a far longer monologue than I planned, I'm not going to go through the phone call with the doctor because it's just more of the same. I think OP is in the wrong here, at the very least in their interaction with the nurse. And I do agree that this is a bad medical system, but you really can't throw the co-pay costs, the lack of automatic prescription extensions/sufficiently large prescriptions to last you a long time and your interaction with the nurse and doctor on one heap and pretend this is the fault of "the American medical system". The overall structure sucks, but some of these people are just local actors who cannot make a change and your friend threatened them to not have to change their schedule.