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Are you told to watch cost of patient care in your residencies?

Discussion in 'General Residency Issues' started by gryffindor, Mar 11, 2007.

  1. gryffindor

    Dentist 10+ Year Member

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    How involved are you as medical residents in the financial end of the treatment you provide? Do your administrators walk around reminding you not to do procedure x or stop ordering test y because of the way it affects your department's bottom line? Do your patients ever ask you "how much will this cost?" and how do you handle that? I assume your priority is to get an education, not worry about your department's financial health.

    Background: I am currently doing my second residency as a dentist. Both hospitals where I have been are private and have well known private med schools attached, although they are in different parts of the country. At both places, the admin always walks around grumbling about our budget and funds almost to the point where it interferes with our education. It doesn't always affect patient health since teeth can always be extracted for cheap, it costs more to save them. But it does affect the tecnology we use and the procedures we learn that are used commonly in private practice but we get almost no experience with during residency. I understand departments need money to operate, but we are in residency to get an education.

    Since many dental procedures are not automatically covered by insurance, we as residents often discuss financial aspects with our patients who want to pay out of pocket for uncovered procedures. We know how much our department charges for procedures and can readily discuss financial options with patients because if a patient agrees and pays, we get the educational experience of doing that procedure. Part of our scut work is ordering supplies from vendors so we know how much it costs to stock and run our clinic on some level.

    I did spend some time on the inpatient floors and did rotations in internal medicine and anesthesia at my first residency. I don't recall any resident, staff member, or attending ever mention the word money, especially when they were seeing patients.
     
  2. adcomm

    adcomm snitch
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    I think there are one or two attendings from each department who tend to be much more in tune with this. One I know carries a list of how much each test and procedure costs and loves to whip it out when you propose ordering something. There are also discussions of cost-effectiveness (especially when ordering diagnostic tests) that happen in a more theoretical way. It doesn't really get diagnosed with patients, though.
     
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  3. NinerNiner999

    NinerNiner999 Senior Member
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    Nope - in EM we pretty much know that nobody will pay their bills anyway... :laugh:
     
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  4. emtji

    emtji Senior Member
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    only if the patient is a self pay do you worry about expenses. but otherwise, no.
     
  5. Winged Scapula

    Winged Scapula Cougariffic!
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    No pressure from administrators, but as with others above, we had a few attendings and senior residents who were more knowledgeable and sensitive to the subject. In addition, because we had a large contingent of self-pay patients (usually Amish), I, for one, tried to make sure that everyone was careful not to order things without a good reason.

    But I can't say I ever got any significant pressure from the suits or anyone else to do so.
     
  6. gudog

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    Every year as a resident, we got a handy little pocket book with all the hospital charges listed, for meds, labs, radiology, procedures, everything.

    They wanted us to know what things cost, but we never got pushback for doing things.

    Also, every week or so, a list appeared on the charts as to the accumulated bill for the hospitalization. It approached $300K on unit patients regularly.

    This was at a large university hospital. I expect you might get more static at a smaller community program
     
  7. Winged Scapula

    Winged Scapula Cougariffic!
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    Interesting, I wish we had that...would be quite helpful.
     
  8. docB

    docB Chronically painful
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    I don't stop the residents from doing tests based only on cost. I do try to get them to think about things with cost in mind. For example if you are going to work up a PE and you know you are going to get a CT there's no point in getting a D Dimer. Don't send patients home with a script for Levaquin if you know they'll never fill it. Write for doxy instead. Stuff like that. We have a thread on the EM board about prescribing tricks.
     
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  9. cchoukal

    cchoukal Senior Member
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    I've never had financial discussions with patients, but our dept (anesthesiology) recently gave us a talk on costs of various drugs, monitors, etc. Many of us were suprised to find out how expensive disposable pulse oximetry probes are, and how much more the pediatric ones are compared to the adult ones. In addition, we were shown figures on the costs of various similar drugs and maintenance costs for our considerable collection of fiberoptic bronchoscopes and associated equipment. I think it is helpful to know these sorts of things; it gave me an appreciation for the importance of taking care of our equipment and really thinking about indications for newer, on-patent drugs.
     
  10. Winged Scapula

    Winged Scapula Cougariffic!
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    I agree its important information to know - if only to "beat" the curious billing practices in hospitals. For example, in our hospital an H&H was more expensive than a full CBC; adding an Ionized Calcium was a lot more. I found that curious and changed my ordering practices to get the cheapest test which would give me (or I could calculate from) the results I needed.
     
  11. danielmd06

    danielmd06 Neurosomnologist
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    Like the more experienced individuals in the posts above, I rarely get pressure to consider costs in day-to-day tests and imaging studies from admin types, but savvy senior residents and attendings attempt to teach me the finer points of compliance.

    On a related note, I once had an IM attending point out to me the basic cost of a hospital bed (and ICU bed), complete with meals and regular nursing care per day. It was a real eye-opener...particularly the ICU. It was something I hadn't really thought about as a third year medical student working desperately on notes every morning, and it gave me a serious respect for what was going on in hospitals from a chronological perspective.
     
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  12. Jejton

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    I had no clue that dentists do residencies. Why internal medicine? Sorry for the off topic post.
     
  13. Jejton

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    Did the booklet list all the costs for everything? I mean that different patients are charged different amounts depending on insurance coverage, self-pay, etc. so did your booklet have everything?
     
  14. Jejton

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    I wont be a student until this summer but I have had extensive experience with the financials of medicine. I think this is a great idea because it will give providers more appreciation for some of the financial burdens patients face, and even just problems with understanding bills.
     
  15. Whisker Barrel Cortex

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    I would add, from the radiology perspective, that its very important for you to put a good indication down for any study ordered, including relevant symptoms and possible diagnoses. If a study is deemed by a patients insurance company to be unnecessary based on the given indication, the patient may be stuck with the bill. Its important to have both symptoms and possible diagnosis because this will maximize the chance they will pay. So a chest x-ray with the indication of "r/o pneumonia" that does not have pneumonia will NOT be covered by many companies. However, a chest x-ray with the history "fever, cough, shortness of breath. r/o pneumonia" will be covered, even if the study is negative. Oddly, if the diagnosis in our report is pneumonia, it'll be covered either way. (at least this is the way it was explained to me).
     
  16. OP
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    gryffindor

    Dentist 10+ Year Member

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    Residency is optional unless you want to practice in New York and I think Delaware. All dental specialists had to do a residency in their specialty, this can be 2 - 6 years depending on the specialty. There are many 1 year non-specialty residencies that are a year of general dentistry, and many of these are located in hospitals. Part of the accreditation for these residencies includes doing some non-dental rotations in the hospital, and for my program that meant internal medicine, anesthesia, and a few other areas.

    It's interesting to read your experiences. I know I am scared to step foot in the hospital because of the unknown nature of what the bill is going to be after I leave.
     
  17. Adcadet

    Adcadet Long way from Gate 27
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    As a sub-i at our VA, I really liked our antibiotic prescribing guide on the EMR (CPRS). You just clicked on "lung" then "pneumonia" then "hospital acquired" (or something like that to find your diagnosis, which covered the majority of my infections) and it gave you the recommended treatment including duration based on local antibiotic resistance patterns. It also included cost per day and journal references. Very cool!
     
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  18. gudog

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    "Charges" are the same for everyone.

    Medicare, Medicaid, PPO's, HMO's, etc. all reimburse differently, some based on charges, some based on diagnoses, some based on contracted per diem rates, etc.
     
  19. anonymousEM

    anonymousEM Senior Member
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    I had a dad refuse to let the trauma team take his daughter for emergency angiography until someone could tell him what it would cost...he had to look out for the "rest of her life" is what he responded when someone told him it was a life-threatening injury that needed to go and that there wasn't anyone in the hospital who had the billing info immediately available. Really, I don't know who I could've called at 3am that would have that info...the rads chief certainly had no idea what the billing was.
     

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