This morning I went to my new primary care physician for the first time. I am at an age where I am still pretty healthy but I am almost at the point where I can be legitimately accused of being middle aged. Given what I do for both a living and for fun, I know the actuarial tables indicate that I will need to spend increasing time with my PCP in the next decade than I have in the previous decade.
As part of the intake process, I had to complete a form of my medical history and relevant history of family members. Duke Primary Care made it easy to do that online so I did that pre-visit as I drank my morning coffee. And then I came to a question of “Anything else relevant….”
I have a high probability of a genetic pre-disposition of certain types of GI tract cancers running in my family. A younger siblings had a screening colonoscopy this year. They found and snipped several polyps.
I’m entering an age band where if I have that genetic variant, I am likely to be at significantly increased risk. I might have it, I might not. I should get a genetic test to confirm whether or not I really need bi-annual colonoscopies at this point in my life.
If I have that gene, it is one hell of a pre-existing condition. I’m fairly confident that I’ll be in the employer sponsored insurance world regulated by ERISA throughout the time that I am at an increased risk. But I am not sure.
I thought for a second, and then wrote it down the pre-existing condition. I’m betting that I don’t have to worry about coverage for that condition in case I actually do have it. But this is the second time in five years where I have had a PCP visit on the same day there was a risk of losing guaranteed issued insurance (NFIB v. Burwell SCOTUS day). Each time, I had to weigh whether or not I needed to be fully open to my doctor or hope that a pre-ex condition would not be a life time anchor against me.
At the end of the visit, the doc wanted me back next week for some labs and we scheduled a colonoscopy for sometime this fall.
Sab
I wanted to say welcome to my world, but that sounded snarky and you are one of us.
Also thank you Canada for the word ‘snark’. It gets the point across without being rude.
Brachiator
Wonderful, clear example of how a genetic pre-disposition could be seen as a pre-existing condition even when no pathology is currently present.
Yarrow
Thanks for this post. It’s a clear explanation of the situation. Glad you are taking care of yourself. We value you and want you to be healthy.
Jerzy Russian
Well, to be fair to the leeches at the insurance companies, you did have genes before you signed up for coverage.
Vhh
@Sab: Actually, snark and snarky appeared in UK in early 1900s and spread to Australia and Canada. Earlier roots probably low German.
Felanius Kootea
Another reason to hope the abomination of a Trumpcare bill fails. I also think companies like 23 and Me will go out of business with a return to discriminating against people with pre existing conditions. I mean who would want to really find out their genetic predispositions if this crap passes?
On a more upbeat (but off-topic) note, Democrats won two special elections in Districts 75 and District 44 in Oklahoma at the state level. Democrat Karen Gaddis beat Republican Tressa Nunley to replace state rep Dan Kirby (a Republican) who resigned after accusations of sexual harassment. Democrat Michael Brooks defeated Republican Joe Griffin to replace state senator Ralph Shortey (a Republican) who faces three felony counts for soliciting sex from a 17 year old boy. Dead girl / live boy indeed.
O. Felix Culpa
I’ve also hesitated to provide full disclosure (e.g. childhood asthma) on medical forms and breathed a huge sigh of relief when the ACA passed. It’s galling that we might be sent back to the bad old days of exclusion/higher rates for preexisting conditions.
Yarrow
@Jerzy Russian: I thought the leeches were the Medicaid recipients. Particularly the elderly in nursing homes who just need to get jobs so they have insurance.
David Anderson
@Sab: I’ve been in that world since at least 2011…
Elmo
Well, this gives me an opportunity to ask the community a question I wouldn’t really know how to bring up otherwise. How does one choose a PCP?
Please limit the finger-wagging if you can, but I’ve never had one. I’m 50 years old, mostly sedentary except for “weekend warrior” construction and gardening projects around the house and hikes into the woods. I eat too much, I drink too much, and I’m fairly chubby as a result. But I’ve never felt the need to see a doctor for anything other than emergent crises – a broken bone here, stitches there, a *bad* bout with the flu a few years back. Generally I’m in terrific health if you overlook how fat I am – I can lift and carry more than most women my age, I can plank for a full minute, and when my wife had back surgery I single-handedly muscled a big, power reclining easy chair out of the truck, up the front steps, and into the house.
I have excellent insurance, and I know at my age I should start getting baselines checked like BP and cholesterol and sugar levels. But how does one start? Do you just cold-call a doctor’s office at random, if they’re in your network? It was easy with my wife, because she needs several different kinds of specialists and has a significant medical history. But me? WTF do I need a doctor for, and how do I pick one?
What saith the wisdom of the jackal community?
Sab
@Jerzy Russian: This is true. Most of my bad genes have no tests yet , but I am sure they will before I try for reimbursement under coverage. I only know about them because they show in older relatives.
Mike J
@Vhh: 1882 is the first cite meaning to find fault with. OED says, “Corresponds to Middle Low German and Low German snarken.”
Sab
@Vhh: Those Canadians are so derivative (i.e. accepting of outside cultural sources.)
BC in Illinois
@Elmo:
It’s all local. There is no widespread advice. I moved about two years ago – – “BC in Illinois” is now in Missouri – – and I just asked around. Local people, friends, acquaintances. My wife and her sister were doing the same. And “trial and error” does include error.
But I know of no other way to proceed then in pumping local people for local information. (The doctor they recommend won’t be taking any new patients, but hey – – it’s a start!)
Jerzy Russian
@Sab: I was attempting to be snarky, but this is very serious business. Everyone is at risk at some point of getting sick and/or injured, and we need the adults in the room to address the deficiencies in our health care system. Unfortunately, as far as I can tell, those adults are not currently serving in Congress.
Tom Levenson
This is one where it seems not entirely off key to talk to one’s doc before committing a statement to paper. Obviously, from a care/social good/personal honesty POV it makes much more sense to disclose everything. But at a moment in history when it is clearly possible that one party might bring ruination on oneself and one’s family…
Sab
@David Anderson: I have been in that world since 2008 that I knew of, and was actually in that world since 2003 when I had my first medical incident at the tender age of 49. All those years of paying for insurance with no costs to the insurance company, and suddenly I became uninsurable at the first medical incident if I had a momentary lapse in coverage.
raven
@Elmo: Get a “wellness” exam. My BCBS covers one every year and it provides a decent baseline.
David Anderson
@Elmo: I chose my current and previous PCP based on the following criteria:
1) In network
2) near my house
3) has availability to take on a new patient
And once I showed up the fourth criteria was needed:
4) Not an asshole
So far both docs that I have seen including the new guy meet the four criteria I use.
My situation is simple, I really don’t need complex care at this time in my life. I am mainly interested in building a relationship so in the contingent future where I need more complex care, I know the person providing that care and I feel comfortable that they are aware of who I am.
People with complicated medical history will use different criteria than me.
As to finding that person — call your insurer, they like to set people up with PCP’s (helps their quality ratings). I asked several of my Duke co-workers if there were any particular recommendations (they are the locals). For my kids pediatricians, I asked the research PCP’s who they use for their kids.
But yeah, word of mouth and then just calling saying you want a “New Patient wellness visit”
David Anderson
@Tom Levenson: But if one discloses to the doc, that puts them in one hell of a legal/ethical risk in an underwriting world.
raven
@David Anderson: I had a GP for abut 10 years who was a former Marine Infantry officer. I started going because a buddy did and just sort of put up with his bullshit. Finally my buddy died and U said “fuck this noise” and signed up with a MD who went to the University of Illinois Med School. She’s just fine, a little too “menu” driven but I can live with that.
sherparick
In the individual marker in the pre-ACA era, insurance companies providing health insurance who had large claims filed against them within five years of someone purchasing insurance would routinely deny coverage based on non-disclosure of a pre-existing condition as defined in the contract and dare the individual to sue them. If sued, they would go through discovery for this very type of thing. I know some of this because attorney I know did this litigation after getting out of the Army for the insurance companies.
FlyingToaster
@Elmo: In general, if no-one’s giving you good recommendations, it’s two online parts:
See if your Insurer has a list of physicians on your plan, and the hospitals where they’re privileged. Then there are generally several local sites that review physicians. The Blues usually do, but then make sure you check if the doctor is accepting new patients, is still on your plan, and is privileged where they claim.
I did this here in MA when my daughter’s first pediatrican retired, and his anointed successor didn’t have privileges at our local hospital. People kept recommending doctors in Cambridge (the city without parking), and I really wanted her doctor less than 10 minutes from my house (i.e., not Cambridge).
.. Edited for spelling
Droppy
That we have to make those kinds of calculations – do I tell my doctor a significant fact that will affect the care I receive or do I withhold it in order to maximize my insurability going forward? – is a picture of why our system is so wrong. We make health care decisions, not health decisions. And “health care” is a euphemism for “what can I afford, what can I get the insurer to pay for, is it worth it, oh fuck it, I’m eating another donut because I’d rather die young than have to figure all this shit out”
Sab
@Tom Levenson: And I had a doctor (elderly) extremely competent dermatologist putting stuff through at a higher (more serious hence more expensive code) because he would get higher reimbursement. He’d be long retired when the sh*t hit the fan, but meanwhile I have a precancerous condition in my file as full-fledged melanoma because he wanted higher reimbursement.
narya
@Elmo: I pick a practice affiliated with a large hospital (I live in a city), and then I rummage through the doc profiles looking for docs whose approach to medicine seems to echo mine. Interestingly, 20 years ago I ended up with a PCP about my age, who retired last year–and who was regarded as “cold” by others. I was fine with her (though I see what they meant), but now have to find a new one. Second the “not an asshole” piece.
grandpa john
Thank God I have had my last colonoscopy. had one 2 years ago doc said it was completely clean with no sign of any polyps and at my age ( 78 then) was not likely to ever have any. I trust my doc since I have known him since his high school days and taught him in high school.when you teach in the same small town high school for 27 years, things like that happen often
zhena gogolia
@David Anderson:
My PCP is a brilliant diagnostician, kind and sympathetic, and funny as hell. Unfortunately he’s the same age as I am, and everyone else in his practice is incompetent or an asshole or both. I’m really dreading the day he says he’s retiring. I don’t know where I’ll go. As it is, if he’s on vacation I just grin and bear whatever condition I’m suffering until he comes back. I feel so lucky to have him as long as I’ve got him.
gbear
I’ve had the same FP doctor for decades. Love him to death.
The last appointment I had with him lasted 1.5 hours because we just kept talking about stuff. The stuff we talked about was my FMLA renewal at work for a chronic illness, and a brand-spankin’-new diabetes diagnosis. Add another check mark to my malady bingo card. I found out I had diabetes on my 63rd birthday. Five days later, my doctor retired. I thought I was in good shape because he was younger than I am.
I’m probably going to stay at the same clinic because they already have my records, but I’m sadder than sad that I have to switch to a new doctor.
Sab
@Droppy: I only learned about his coding upgrade when Anthem Blue Cross denied me coverage after I had been paying premiums for four years because I had failed to report a pre-existing condition I didn’t know I had because he never told me because he knew I didn’t actually have it but he wanted the higher reimbursement.
d58826
twitter.com/ASlavitt/status/885531195840266240
gene108
@Elmo:
I too need a new PCP, mine is retiring.
Advice is welcome.
Betsy
The related question about telling your doctor about your health and life is that you have to trust that the electronic medical record is secure and that the information won’t migrate elsewhere. Lots of diagnostic status codes we might not want to be disseminated.
d58826
Totally OT but the photo of Steve in the oversize recliner makes sense because he is an oversized cat. The felines of the world thank Cole for being so thoughtful
Alternative Fax, a hip hop artist from Idaho
@Sab: How did you get it sorted out? Hoping that you managed to. That’s the kind of shit docs should face discipline – and litigation – for. It’s 17 kinds of wrong.
d58826
more on truimp care from twitter twitter.com/ASlavitt/status/885533787328794625
Villago Delenda Est
Well, according to Mitch McConnell, if you have a pre-existing condition and can’t afford to deal with it out of pocket, you die.
OK, so you’re walking down a road on a hot sunny day. Mitch McConnell is lying in the middle of the road ahead of you, stuck on his back, he can’t turn over to get up. If he stays that way, he’ll roast in the hot sun and die.
What do you do?
Nicole
I had my first colonoscopy this year, David, also due to a gene that comes with a (possible) increased risk. Said gene was discovered when I was diagnosed with breast cancer in 2016. Sigh. (Spoiler alert; had surgery, all seems clear; I just now get to spend the rest of my life fearing distant recurrence and a lack of access to affordable medical care should that happen).
The discovery of genetic influence on disease is one of the most important advances of the 20th century and the thought that insurance companies’ desire not to pay for health care and the GOP’s desire to give the wealthy tax cuts might lead to people being afraid of genetic testing produces so much fucking rage in me that I fear my heart will explode before cancer gets me (if, indeed, that is what finally does it).
Colonoscopy was easy peasy, though, and the intestines were clear. Glad you’re getting it done. Due to the gene, I get to go back in 4 years, instead of the usual 10, but c’est la vie. I only hope I still have insurance that covers it 4 years from now.
And a sad thought- my mom died of breast cancer when she was 35, back in the early 1980s. She had both her kids before age 30 and breast fed us both for a long period. She went to her grave convinced that she got cancer because she took birth control pills in her early 20s (and yeah, it wasn’t until the 1990s that they finally concluded it was highly unlikely birth control pills had any effect on getting breast cancer. Hell, I remember being told by doctors as a teenager not to eat chocolate or drink coffee or soda because they thought caffeine might cause breast cancer). And yet, likely it was just all in my mom’s genes; there is nothing she could have done. Though I imagine the GOP would happily look for some reason it was her “fault.”
Villago Delenda Est
@gbear: My PCP was my age, or a tad younger, thin as a rail, ran 4 miles every day, and died 20 years ago.
Yarrow
@gene108: Ask around with friends, neighbors, co-workers, whoever you trust. Check hospital admitting privileges and see if they’re in your insurance. Also, check to see if they take a lot of insurance in case yours changes–this happens and suddenly your doctor isn’t in your network.
gbear
@d58826:
I read the breaking stories from both the WaPo and NYT. The WaPo focuses on the below-basic coverage and the damage that will do while the NYT starts out with higher-subsidies and no tax cuts. They’re kind of trying to make it seem viable.
Yarrow
@Villago Delenda Est:
Well, you see, since I can’t afford medical care I have a few medical conditions that would preclude me being able to turn over and help to his feet an upturned Mitch McConnell. Sad!
d58826
I wonder how much healthcare could be funded if you took all of the hours that the GOP has spent on repeal/replace and multiplied it by the federal minimum wage? I suspect that would add up to a nice piece of change.
Kelly
@Elmo: When I retired and moved back to my old home town I went with the son of our family doc from when I was growing up here. It’s worked out OK. In a small town/rural area there weren’t many to chose from.
At 61 and 57 my wife and I are in good enough health to be active, outdoorsy hikers, cross country skiers and whitewater kayakers. And yet we each have several things that could be pre-existing conditions. When we got together just before Obamacare passed she had lost her health insurance due to financial difficulties and could not find new coverage.
sheila in nc
I feel immensely fortunate to have access to a fine academic medical center for all of my health needs. PCP, GI medicine, a couple of surgeries, oncology, dermatology, ophthalm, ortho, PT. Shingles last fall, knee therapy in February, lung cancer surgery in March, back on the tennis courts in April, they’ve got my back (and all the rest of me!) and they can easily communicate with each other and view my entire set of medical records. That said, my dearly beloved GI just retired from practice (he’s devoting full time to research) and I haven’t met the replacement yet (but the outgoing doc told me he had picked out the new guy and trained him personally.) Sad to say, the older we get, the more inevitable it becomes that the healthcare professionals we rely upon will be subject to turnover.
Nicole
@Elmo: I second (third, fourth, fifth) the asking around to find a GP, but the other thing you can do is find a doctor your plan covers, and then google them. There are a lot of sites devoted to consumer reviews of doctors. You have to be able to mentally sift out reviews by the crazy folk who will complain about anything, but I find it really helpful when looking for a new doctor.
(That was also how I found out my stepmom’s periodontist had been accused of secretly watching his female employees while they were in the bathroom.)
gene108
@Villago Delenda Est:
Kick him in the nuts as hard as I can. Over and over and over again. Then go on my way.
Edit: With a smile on my face.
pamelabrown53
@Elmo: @10.
Elmo, I want to thank you for your comment. I am a person who is seriously remiss when it comes to medical issues. Since, I’ve had so few. I turned 64 end of April and need to get a real primary care doctor and start getting some baselines.
Anyway, because of your comment I called BCBS FL. to ask for an updated list of primary care doctors Since I have individual insurance, I also found that with my July premium rate increase, I’m now spending 697.00 per month. Thank Jeebus, I’m eligible for medicare in less than a year! Even with the supplemental policies, hopefully, I’ll cut that payment in @ half.
Again, thank you. If not for your comment I’d still have my head up my ass.
gbear
@Villago Delenda Est:
My retired doctor is going to take a break and then find a position at a nursing home. His patients were actually asking him which home he was going to work at so they could go there when they fall apart.
d58826
@gene108: Make a quick trip to the 7-11 for a jar of honey. Pour it over Yurtle to help the ants finds him while he is still alive.
Sab
@Sab: I didn’t sort it out. He’s in his eighties. My husband likes him. If I raised a stink about it he would probably have died of old age before anything was resolved. I switched doctors, and now I insist on a printout of everything, which is my right under Obamacare. So going forward I will read what they report and challenge things I have issues with.
If Obamacare gets repealed I am screwed until medicare kicks
in.
This was meant to respond to Alternative Facts, not to myself.
Villago Delenda Est
@gbear: He sounds like the sort of doctor I’d follow to the ends of the Earth. My family physician when I was a kid was like that; he was the UO football team’s doctor for many years. They guy who took over for him when he retired was the one that passed far too early, he was a good guy too.
Now I’m with the VA, and I’ve got a good PCP who just took over for a good PCP who retired last year.
Villago Delenda Est
@gene108: The smile means you’re probably not a replicant!
J R in WV
@Sab:
You should have sued the Dr the instant you found out about his fraud – and Anthem Blue Cross would have / should have sued or prosecuted (it is a felony!) the minute you told them, if you told them.
Your dermatologist was an incompetent lying thieving fuqwad!
ruckus
@Elmo:
Try whoever is closest/easiest. You have to give them a chance, an interview if you will.
I get assigned a PCP at the VA, you only have a choice to change, not select in the first place. I’ve been there 5 years and so far it’s worked out fine. I’m on my fifth at this point. They have all switched jobs all of them were OK.
maurinsky
I go to a Family Practice Group that is staffed by residents, with a PCP who I only see when the resident is unsure. I love going to this place, the young doctors are much better listeners, and there’s only been one dud since 1996 (and I requested a different doctor and the new one was terrific).
The last time I went for a check-up, my blood pressure was higher than usual, as was my blood sugar. Neither were high enough to require anything special, but I decided I had to lose some weight and kick my sweet tooth out before I went back again, because I don’t want a diabetes or pre-diabetes on my medical records. I actually went in earlier this week for an allergic reaction to mosquito bites, and my blood pressure was back down to 120/76 and I’d lost 23 lbs, so I might be making an appointment for a physical in another month or two and get the bloodwork done and my current healthy state on the record.
I was born with hip displaysia and then had Legg Calve Perthes, so I have a bum hip and I will always have it because the surgery would be very tricky due to osteotemy surgery I had when I was 1 and half years old – the ball of my femur is facing the wrong direction and no one wants to replace it. Luckily, I also have ankylosing spondylitis, which prevents the joint from moving and therefore reduces pain.
Laura
@Elmo: ask around, but in my humble opinion the Key Thing is to establish a good, candid relationship with your PCP. I’m in Kaiser and have seen a variety of PCPs. My current is tops because she takes the extra time to talk to me and it’s the best doctor/patient relationship I’ve had since the early 80’s. It’s so good that the spouse and two close friends have selected her as well.
That relationship and partnership gives me great peace of mind, and in the future, when the inevitable scary stuff comes up, she has my trust.
Alternative Fax, a hip hop artist from Idaho
@Sab: I suggest you consult counsel w/r/t getting the records corrected, since this can be an enormously expensive “mistake” (also known in the industry as insurance fraud). Never mind the fraud issues – for you the important thing is having accurate records.
Of course that’s very easy for me to say.
sheila in nc
@Sab: The trouble with not making a stink is: he’s probably done this to other patients as well. They may not know about it. They may have suffered loss of coverage because of it.
Capri
All this has really come home for me as I just learned that my first grandchild has cystic fibrosis – diagnosed at 20 weeks pregnancy. .That’s a pre-existing condition that there’s no getting around. There is a miracle drug that reverses most of the symptoms, that costs a mere $300,000 a year out of pocket. Just thinking of the future issues with insurance and medical care is a nightmare without dreading how future GOP congresses will make everything more difficult and expensive. Moving to Canada or some other civilized country makes a lot of sense right now.
bluefoot
@Elmo: My criteria were: reasonably convenient to home and/or work, in my network, checked if they had any subspecialties (for instance, a friend has a PCP who also works on autoimmune diseases) and board certifications, and with which hospitals they were affiliated since there are several close to me. I have also checked the size of the medial group/practice to which they belong – i.e. is there sufficient coverage if the doctor is out or we have a big snowstorm.
Percysowner
@Elmo: Lots of good suggestions here. I’ve lucked out with PCP for most of my life. Do you have a dentist or an optometrist? Either one may know medical professionals in your area and can give you a recommendation. If not, use the list your insurer makes, get one close to you. Also, check scheduling. My favorite PCP had evening and Saturday hours, which were a godsend when I was working 9:00-5:00. If you have to schedule time to go, that can make a big difference.
Ab_Normal
@maurinsky:
I think you may be the first person in history to use “luckily” and “ankylosing spondylitis” together in that manner…