I received a bill in the mail the other day, recapping the costs from the most recent visit with my endocrinologist here in Southeast Michigan. One particular fee caught my eye, and made do a double-take in terms of reviewing just exactly what I'm paying for when going to see my diabetes doctor. Instead of a tidy little co-pay, a larger dollar amount screamed from the statement, delivering what felt like a punch to the gut. On top of that, this additional charge caught me off-guard:

an $85 charge for reviewing CGM data

This is the 8th endo I've seen in the three-and-a-half decades with type 1 diabetes, and while this is by no means the highest bill I've ever been sent for a single office visit, that particular fee ruffled my feathers more than others.

Yes, my insurance company covered a small percentage, but I was left paying for the brunt of it on top of the co-pay I had paid on-site and some other miscellaneous fees that weren't fully paid for by the insurer. My head, heart, and wallet were hurting. It made me cringe, having to once again accept not only the high cost of healthcare overall, but also these high fees charged for a pretty routine appointment. As most appointments go, my doctor and I had spent most of that recent visit in August discussing basics and figuring out which steps to take next with my D-management.

Sure, I've noticed the fee schedule before: a $5 processing charge for calling in a prescription; $10 for obtaining blood sugar logs or lab documents; and $25 for a pre-authorization letter to insurance or a form letter for traveling. These "physician services" seem like basic parts of the job -- but I tried to keep an open mind about how overworked many practices are, and the fact that these fees are often used as reminders to patients (i.e. they can sometimes be waived if patients are proactive and call ahead). More doctors are charging extra fees for services like this, especially as we bring in more complicated D-tech and data tools that require more time and energy to analyze. It's understandable, from that business POV.

That and the fact that I should be used to this by now... but when this recent bill arrived, I felt my blood pressure skyrocketing, as I scanned the statement over and over. I started wondering what it would be like if I, as a patient, could bill my endo for charges related to his care.

So, I've penned my own "Patient Services Bill," below. (Naturally this is a tongue-in-cheek way to vent my frustrations.)

 

Statement for Patient Services to Physician

Prescription Filling: $35

Every endo I've ever seen has been willing to call in my prescriptions to the local pharmacy, or give me a written Rx slip to take in myself, even if it's not the day of my appointment (because sometimes you need a refill on the fly, or want to try a new medication before the next visit three months down the road).

Sometimes, it takes time to get a return call or to serve as the go-between for the doctor's office and pharmacy. I hereby bill you at a rate of $10/day, as well as a $5 surcharge because your office closes at 2pm on Fridays, requiring me to adjust my work schedule if I need to see or communicate with you.

Diabetes Device Fee: $20

You charge a fee for reviewing my device data. That's only fair. But I also carry the burden of bringing in my device, loaded with meaningful data. My rate for that is $10 per device, a considerable discount from the $85 (pre-insurance amount) you ended up charging me to download and review my CGM data alone. Believe me, we patients spend more time reviewing our data each day than you do in that short time-window, so we should be compensated for data interpretation too.

Provider's Online Records Portal: $10

You require me to use your provider-optimized online system, Patient Fusion. I'll admit it's cool seeing all my info there online, even if I did need to take time to learn this system... But then, after our appointment, I received a handful of emails from Patient Fusion, plus a survey about our last visit. This required time out of my workday to register, log in, and review the content. I hereby assess a $10 fee for this, just as you charge for downloading and reviewing my data and interpreting my lab work.

Lost CGM Data Reimbursement: 26 cents

When you take my Dexcom away from me, that means it's out of range while you're off downloading data to review. In this case it was a nearly 30-minute interval, for which I hereby charge you. How did I calculate the cost? It's D-Math: My monthly cost of a box of four G5 sensors, divided by 4, divided by the FDA-dictated 7 days of wear, times the number of minutes you had my Dexcom in quarantine. This one's not a lot of money, but I want it back.

Phone Tag/Aggravation Service Charge : $1.01

We exchanged no less than nine phone calls related to my care between my most recent appointments. A majority of those were return calls to me, as you (the practice) didn't have ready answers to my questions so had to follow up yet another day. Most recently, I phoned your office to ask about a $10 charge on my bill that I didn't understand. Nope, I had to call a billing service instead. That person read the fee off the bill to me, but couldn't explain what it was actually for. So, an account manager would need to investigate and return my call. This took another two days.

Each month, I spend $50.82 for my business phone line. These doctor calls* took up roughly 2% of my time during the past month; the IRS allows for 2% reimbursement.

*No extra surcharge is being assessed for the non-returned calls, or 24+ hour waiting periods when I was left hanging with anticipation.

Marketing and Publicity: $50

When I first started going to see you after moving back to Michigan, I wrote a post specifically about how great that first visit was based on yor expertise, ability to listen to what I needed, and your willingness to embrace the Diabetes Online Community. Although my intention wasn't really to plug you (but just to share my real-world patient experiences), I am now reconsidering billing this as marketing/goodwill publicity, and awareness-raising for diabetes doctor-patient relationships.

I equate this to the standard $50 you charge for a personalized letter detailing my medical necessities, for me to use while traveling.

Total Charges: $116.01

Empowered Patient Discount = 50%

Amount Due By Physician: $58

 

Please note: insurance coverage and CMS reimbursement may vary. In order to ensure prompt service and responsiveness, please have your payment ready at time of office visit, prior to any patient payment of co-pays or co-insurance fees. Thank you for your understanding.

- The Diabetes Headquarters of Michael Hoskins, Type 1 since 1984 -

 

My Endo's Office Should Be Like a Car Repair Shop

OK, I had fun compiling the above. But it's a serious topic, to be sure. I really do think seeing my doctor for a "diabetes tune-up" should be like going to a mechanic to have them check your vehicle; you should be able to get a rundown of all the proposed services and costs and be able to choose what work you want done, and don't.

We should at least offered a package plan that includes many services for one combined fee (aka a set co-pay). The problem is, being nickel-and-dimed on all these disparate fees, by both the doctor's office AND the insurance plan. I don't actually know what I am going to see on my bill that arrives two or more weeks after that appointment. Why is it not possible for me to pick and choose at the time of the doctor's visit?

I understand that the most critical part of each visit involves my CGM data, which shows my doctor all kinds of important glucose trend data. It's also the most costly to analyze. I also realize that doctors do not receive full insurance reimbursement for their time reviewing CGM data.

So maybe as a patient I should plan to print out my recent CGM data on paper and take those in, or even analyze the info myself before the visit and jot down notes for my doctor. But that's just making my life with diabetes that much more difficult! And it would likely take even more time than an on-site CGM data review -- and could subsequently lead to an even higher fee. Ugh.

I get it that doctors need to be paid for this, but why is the burden of cost landing on the patient? Do all endos list "CGM data review" as a separate line item on their bills, charging in the neighborhood of $85 per visit?!

 

The Business of Diabetes Care

I know some doctors do seem very fee-happy these days, and these costs can be hard to stomach on top of all the other expenses we have related to diabetes. Hell, insulin pricing in itself is outrageous even with the best insurance coverage (let alone those who don't have that kind of privilege). But this is the world we live in now, and even as we fight for change and more affordability and access on various fronts we're forced to deal with these bills.

Personally, I really do value the insight and experience of a trained medical professional who probably has some very good advice to offer me. Yet at the same time, what about patient autonomy?

I have to pay a lot of money to manage my diabetes adequately, so why can't I choose what services may or may not be worth the extra cost during an endo visit?

It's a business being an endo, I get that. Well, hell. It's a business being a patient too.

What I'm saying is that providing healthcare, and diabetes expertise, isn't easy and it's not cheap. It takes time, energy, and money -- just as it does to live with these chronic illnesses. There needs to be a balance...

Meaning, if there's anything that needs to be fixed in our messed-up healthcare system, it's creating a structure where doctors aren't forced to take a loss doing the simplest parts of their jobs -- but also where we patients aren't being forced to foot the bill on multiple charges for every little thing, or even things that may not actually be needed.

We have to meet halfway on this, because at the end of the day we're really in this together.

{Turns his gaze overseas to wonder how other countries do it...}