Friendly Neighborhood Patient

You might look out to the ocean and see the tiny lip of what becomes a massive wave by the time it hits the shore. In the world of healthcare, that phenomenon would be like investors buying up hospitals and clinics of all kinds. Corporations are joining the fray as well—they, like anyone else, want to cut their medical expenses. Mainstream press focuses on the “greedy corporate overlord” narrative whenever a nonmedical business buys a clinic. Under this theme, such moves could be anticompetitive and kill the care patients get. There's some truth to those outcomes. Yet the reality of investor-owned medical offices is nuanced. There are more layers to ownership-based incentives now than even before. This episode's here to tell you why someone buying a clinic brings massive consequences for patients everywhere. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

There's no doubt that our medical system's expensive to a point of comedic tragedy. No shortage of private and public entities have tried to make medicine cheaper. Ironically, the federal government tries to spend money to save you money in healthcare. Enter the subsidy, an economic instrument both loved and detested by many. Subsidies are used in many parts of the economy, but with medical care in particular, the feds tackle drug development and health insurance among other sectors. Today's episode tells you why assistance with medical funding makes healthcare both cheaper and pricier for you. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

You've heard of doctors and nurses. Physician assistants have been on the scene as well. But not all medical doctors have the same degree. Sometimes you might see doctors the letters DO following their names instead of MD. The DO, or Doctor of Osteopathic medicine, has similar base training to an MD, but with more emphasis on treating someone within context of the entire person. Don't be ashamed if you haven't heard of such a doctor—according to the American Osteopathic Association (AOA), about one in five Americans don't even know that DOs exist. Patients who know the difference between and where their kinds of doctors come from will have more success with building a great medical relationship. This episode's covering everything you need to know about DOs in the grand scheme of medicine as well as how to pick them properly. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

It's totally normal for people to ask where their food comes from but we don't always do this for prescription drugs. Every medication has to get from a lab to your pill bottle somehow. Ever since the Covid pandemic and the quick approval of its vaccines, patients became more aware of how modern medicine comes about. Our drug approval system has more nuance than just expensive 10-year challenges and quick 12-month emergencies. Let today's episode be a simple crash course about how our country approves drugs and the first steps to untangle that messy, twisted process for the better. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Never blame a patient for wanting to save money. Especially for meds. Insurance companies also would like to nickel-and-dime manufacturers when possible. High drug prices are a mainstay in the news. That said, a whole world of prescription discounts is right around the corner. Medication discount cards and coupons are everywhere, but patients still need to be careful with using those savings. Episode 38's dedicated to helping you wade through the swamp of a drug discount world we have. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Your phone might stick around wherever you go, but your medical care may not follow suit. When the time comes for you to move to a new state, change jobs, or both, your health plans and doctors would need to change as well. Insurance plans and medicine are (mostly) locked within state lines. Closed-loop healthcare built in the 20th century is part of why our current medical system gets expensive. Yet we live in a connected world where it's perfectly normal to work from anywhere and move state-to-state like we're crossing the street. In this pod, I'll make our fragmented market simpler to understand so you know how to get medical care organized on the go. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Your smartwatch talks a lot but may not say much about your health. Constant data collection from wearables claims to improve medicine at large. Is the ‘quantified self' the next step for patients or is it just a gimmick? Does healthcare improve when doctors access your live data on a whim? After today's episode, you'll learn to trust your wearables at the right time rather than all the time. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Learning never stops—that goes double for medicine.Doctors have vast knowledge but they need to remain sharp. Every year we find new diseases, innovations, and drugs. The physicians keeping up with their craft among other requirements are “board-certified.” Why should patients care for that title? After this pod, you'll know what a board-certified doctor means as well as helpful tools to find a solid one. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Unless you happen to be lucky, you're probably getting prescribed something in your lifetime. It could be one medication. Or you might need a pill calendar. In any case, you'll have to deal with a pharmacy. Your doctor's passing the ball and setting you up for success whether that be through a treatment plan, medication regimen, or a combination. Hearing today's episode will help you deal with the local pharmacies and pharmacists to ensure you get in the end-zone for your healthcare. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Who remembers the good old house call days? Some may imagine a doctor strolling into their home with a well-worn briefcase and curled-up stethoscope. Newer technologies are making the house call a thing again. See Episode #33 of Friendly Neighborhood Patient to know the uses and limits of home health. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Some people are tired and others are permanently drained. No matter the profession, if you have no energy, your abilities suffer. Medicine is a demanding field, no doubt, and we should expect our providers to be resolute and intelligent. Why should patients care about their doctor's well-being? Doctors also happen to be human beings—they too can feel the vice-grip of burnout. A burned-out physician hurts your care and threatens any chance of having a great medical relationship. Patients need to recognize when their doctor isn't fully present or just going through motions. In today's episode, you'll learn how to spot the signs of provider burnout.There are so many sources about workplace exhaustion—everyone has an opinion about the subject, and rightly so. Of all this issue's possible angles to comment on, the consequences to patients are the focus. Drained physicians are dangerous not only to themselves but also to patients carrying the consequences of that exhaustion. Patients need to know why providers get burned out and how that weariness is a personal and systemic problem. Doctors are people too—they make errors like the rest of mankind. That doesn't mean patients have to stop holding physicians a higher standard. Rather, the patients able to identify burnout can either switch to another provider or make an effort to repair the sacred patient-doctor relationship for the better. These options present themselves only after having a clear idea of what occupational exhaustion is.Burnout is both a nature and nurture phenomenon. Some people have an innate disposition for work to suck away their well-being. Others may be vigilant but their organization could bring unnecessary pressure to perform. The problem at hand isn't hard to find. According to Medscape's most recent annual burnout report, ~47% of physicians are burned out. The study's main criteria defining burnout revolved around depersonalization and lack of fulfillment from work. ~60% of surveyed physicians noted that excessive bureaucratic demands of their respective workplaces were a cause of their exhaustion. Regarding internal characteristics, ~33% of doctors reported burnout having a direct connection with personality. Per the study's parameters, common symptoms included more irritability, less patience, trouble with concentration, and full lack of empathy. A doctor unable to care for themselves won't be able to care for you long-term. For simple medical problems, burnout may not be an issue, but when medical conditions get complex, the provider's lack of energy becomes palpable. Burned-out physicians don't last in one place for long. Excessive turnover stunts the continuity of any patient-doctor relationship. Even if the treatment is spot-on, the experience at the clinic could be awful.Physician burnout itself was classified as a thing back in the 90's. Providers generally agree that stress precedes burnout. Of course, a million things at the office can raise your blood pressure. Stress is a part of being a medical professional since, well, life is at stake with every decision. Researchers from the Stat Pearls medical education database list a host of burnout catalysts. Piling on more hours, spending more time entering medical data instead of seeing patients, a laser-like focus on productivity, and lack of support from peers to draw meaning from work are the factors standing out the most. The worst possible journey that can happen is stress creating burnout, with the compensation for that burnout leading to fatigue, depression, and even suicide. Patients can't always see how eroded a physician becomes with time. However, patients do know when they're treated badly. More diagnostic errors. Lack of engagement. Less safety checks. Even the most high-functioning burnt-out provider can't avoid those mistakes forever. The greater challenge for both patients and doctors is the fact that burnout's easy to misdiagnose. Someone could just be chronically tired. Any number of outside factors affect social versus clinical depression. Addiction or general anxiety could also be a predisposition that can't be fixed without major intervention. Sometimes a doctor enjoys their job but has the personality of a stone statue. It's easier to play whack-a-mole than identify your doctor's burnout ahead of time.Many have tried to explain workplace exhaustion, but one physician in particular built a helpful framework. Dike Drummond, a family medicine doctor who runs an empowerment organization called ‘The Happy MD,' believes in three kinds of energy—physical, spiritual, and emotional. Burnout happens when there's a deficit in those categories. Exhausted doctors can still forge on if they're drained, just like how a government can operate in the red, but with a steep cost. Seeing patients for long hours without taking enough time to eat and sleep well is just the standard of medical training. Doctors also have to bear the weight of their patients' many issues. Taking in hundreds of patients' needs a day numbs physicians' emotional capacity. At the spiritual level, physicians need to feel validated for choosing their profession, along the lines of “this is why I chose to practice medicine.” Not having enough of these moments breeds professional hopelessness. Physicians then begin to tell themselves “I'm not sure I can keep this up,” or “why should I bother doing more for my patients if my work doesn't mean much to them?” Dr. Drummond argues that providers can recharge their batteries through building personal relationships outside of the clinic and taking pride in the best patient outcomes. I'll link his work's detailed follow-up on my page at rushinagalla.subtack.com.This burnout concept is reflective to doctors themselves, but where do patients fit in? Patients can set up meaningful interactions by wanting to be involved in their care and by demonstrating appreciation to the doctor. I'm not staying you should write a thank-you note to every provider, but taking a short moment to thank your physician for their help in a small but focused way might just prevent their career from eroding their soul. Healing burnout at the individual level is wonderful, but persistent organizational dysfunction (e.g. a toxic or high-pressure workplace) blocks any progress. Systemic incentives die hard. Government organizations like the Agency for Healthcare Research and Quality argue for implementing flexible schedules and delegating work to mid-level staff to combat the pressures of medicine (e.g. time slots, data entry, general chaos). These are classic “sounds good, doesn't work” policies. Most physicians and their employers make their income through volume more so than outcomes. Obviously, everyone steers clear of a bad clinic—healthcare still obeys some market laws. Imagine two primary care clinics with doctors accepting insurance plans with similar payouts. Clinic A has better staff and training (i.e. more doctors with expertise on specific conditions using less mid-level staff), but clinic B sees 50% more patients. Clinic B stays in business while A goes under. It's that simple. If a medical office's staff each need to see 100 patients a day and earn an average of ~$500-$1000 per insurance claim after contract deductions (assuming this is a traditional outpatient consultative practice), rational providers will see that many patients at whatever personal cost, including well-being. Our country's insurance plans and the nature of American medical training need some reform (to say the least). I'll spend more time on possible solutions in a future episode, but asking patients to fix those nationwide issues is too unreasonable outside of voting for someone with enough political will to handle the challenge.It's not all doom and gloom. Patients can still play a role in erasing burnout through collaborating with (rather than submitting to) their doctor, asking thoughtful questions, and demonstrating appreciation to the doctor for handling the demanding realities of medicine. Give your doctor assurance of their chosen profession being a positive and noble choice. Medicine is meant to be a craft, not an impersonal transaction performed in some beige-painted, windowless exam room. Thanks to telemedicine and new technologies, more providers are having somewhat of a blast to the past in practicing medicine outside of the clinic. House calls are (kind of) getting back into fashion. In the next pod, you'll find out if home health is all the rage or just a gimmick. Subscribe and stay tuned to Friendly Neighborhood Patient to know what matters most to healthcare consumers. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

In the old days, we called them doctors. Now everyone sees a “provider.” Many other professionals from the scribe to the physician assistant complement the doctor. These positions are supposed to make the clinic experience better for all patients. You might have a choice to see a nurse practitioner now or wait longer for your physician. In some places, you may not ever see a doctor again unless your medical condition is complicated or severe. Given how quickly norms change, patients need to ask two questions. Should nurses and physician assistants play a bigger role in medicine? And more importantly, do they deserve the patient's trust? The answers reveal much about why you should care deeply about who's responsible for your health.Titles carry heavy weight in medicine.Doctors of course have been around since ancient times. Nursing as we know it began with Florence Nightingale in the 1800s. Physician assistants, or “PAs,” were a product of the US military in the 1960s. These roles evolved with time. Doctors specialize and then sub-specialize with their interests. Nurses target various patient groups and can practice medicine as well after proper training. PAs can plug themselves into nearly any medical discipline. For today, I'm just going to focus on why nurses and PAs are building a larger foothold in overall patient care. Some economists believe that PAs and nurse practitioners (NPs) should replace all primary and standard care in America so doctors can instead handle the most complex problems. That's a dramatic change some argue is happening as we speak. Before weighing in on that major trend, patients must know the exact roles of their non-doctor providers. Understanding each of these professionals' responsibilities is the first step to questioning if they're doing their job right.You've probably met a registered nurse (RN) at least once. An RN takes many forms, whether it be a midwife, anesthetist, or a practitioner. Most nurses find themselves in broad medical categories like primary care and women's health. NPs can do more tasks than a general RN can. PAs usually specialize by medical discipline as physicians do. Both NPs and PAs have overlapping skills, but their training differs. Nursing school after undergrad focuses more on treating the patient in a given care setting and PA school is centered on treating the disease (similar to traditional med school training). PAs usually have a few years of clinical experience (normally as a medical assistant) post-undergrad before enrolling in a two- to three-year PA school. NPs need a master's degree to become an RN first, then finish a graduate degree and licensing exam. In certain states, NPs can practice independently without doctor oversight. PAs on the other hand legally need physician supervision. To put the education in context, a PA or NP likely spends a maximum or four to five years, including job experience, after undergrad before practicing medicine. A physician spends about eight to 12 years after undergrad (depending on the specialty) before they can see a patient. That's a lot of school. If someone asks you who to trust with your care, it's an easy choice. However, we do not live that kind of a vacuum. Reality has other ideas. As I've said in past episodes, there are only so many doctors to go around while healthcare usage climbs.The differences in providers' training are one thing, but the demand for NPs and PAs in particular keeps rising. Markets are saying their piece—according to the Bureau of Labor Statistics, the number of PAs is projected to grow ~30% between 2020 and 2030. For all nurses (RNs, NPs, etc.) the forecast is 45%. Doctors' estimated job growth is sitting at just 3%. I'll link the more detailed BLS data on my page at rushinagalla.substack.com. The largest driver behind these expectations by far is nationwide aging. Chronic diseases like diabetes and heart issues play a role too, but nonetheless, PAs and NPs are necessary to keep up with secular trends bringing about more patients in need.Let's be practical for a bit. When heading to the clinic to deal with a medical issue, you may or may not have a choice in who you see. If you draw a Venn diagram of the tasks that doctors, NPs, and PAs can do, there are several commonalities in the middle. All three of those professionals can do physical exams, make diagnostic assessments, order tests, prescribe meds, and perform routine procedures (e.g. biopsies, injections). Yes, even surgeons have PAs who know how to hold a scalpel. ~19% of PAs pick a surgical sub-specialty. From the patients' viewpoint, these basic clinical skills are everything medicine appears to be. NPs and PAs likely do a few other administrative tasks the physicians don't need to worry about, but you shouldn't get blamed for believing that doctors and other providers are interchangeable for certain responsibilities. In the heat of the moment, two providers (with different degrees) writing the same prescription or doing the same routine procedure appear to deliver equivalent service. It's no coincidence that NPs and PAs command a much lower median salary ($121K and 124K, respectively) than what a physician can claim ($200K+ depending on specialty and practice setting). What you can't visualize are the wide gaps in education and experience unless you have a complex medical issue.So what should you do if there's a choice to wait longer for the doctor or see the NP or PA now? Your condition drives the answer to this question. At the same time, patients should prioritize getting seen rather than waiting for an experienced professional—if your condition is unusual or too complicated for a PA, you'll get referred to a doctor quickly. PAs in particular have been fighting for looser oversight restrictions since the advent of their position. In May 2021, the main PA society changed its name to the American Academy of Physician Associates (rather than ‘assistants'). Doctors weren't exactly pleased with that development. Groups like the policy-focused American Medical Association pushed back, arguing that changing titles will confuse patients. Anti-PA sentiment points out that midlevel providers handling too many patients cause more errors. Pro-PA sentiment suggests instead that doctors can use extender staff to free up time away from routine care and onto the difficult patients. Most state legislatures and regulatory bodies haven't enshrined the new “associate” term. Doctors may be disgruntled, but they're still employing new midlevel staff to handle demand. Market forces are still at play. PAs can exist in any care setting, but ~53% of them are employed at doctors' offices (vs. 47% for nurses).I do not believe patients have to settle for a winner-take-all reality. Patients shouldn't let their doctors be unreachable. But patients shouldn't also toss NPs and PAs to the curb. Both of those midlevel providers share some abilities with the physician, and in most settings, can spend more time with you. Patients are trading medical experience for accessibility. Some people are uncomfortable with that truth, especially because medicine is a field where oversimplification—'patient A has a given disease, takes treatment X and recovers well'—is dangerous. Give PAs and NPs the opportunity to become the modern, first-line PCP to deal with your problems in a timely manner before the doctor steps in. However, use what you learned in this episode to know the limits and bias of each provider you'll meet in your healthcare journey. Physicians with multi-decade careers or brief stints after graduation have adventures of their own. Sometimes their struggles manifest in ugly ways, hurting both themselves and their patients. The next pod will cover the essence of doctor burnout and the role patients like yourself have in helping physicians feel better about their job. Subscribe and stay tuned to Friendly Neighborhood Patient for medical field breakdowns. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Have you ever heard something nice about Medicare in the last few years? It's the behemoth among our country's fragmented medical systems. We also pay for it with taxes. So why is it always close to running out of money? Today you'll learn what insolvency means, how our national coverage actually works, and what we should do about their unintended consequences.Patients have a right to know what they're paying for. Medicare, our national insurance for seniors, is no exception. Knowing that an entitlement will be weaker by the time you age into it is the first step in preparing for other coverage ahead of time. As of this year, the Medicare Board of Trustees still estimates our national insurance for seniors will become insolvent in 2028. That's an improvement from last year's report claiming 2026 as the doomsday. I'll spend a bit of time later on the economics behind that, but what does insolvency mean? What happens when Medicare runs out of money? It's best to start with how the program's funded. It turns out taking care of the country's seniors isn't cheap. The full cost of Medicare is 12% of our federal budget. However, Medicare did make a surplus in 2021 behind $888B of revenues. ~80% of that is funded by a combo of general income taxes and payroll taxes. The Medicare and Social Security taxes draining your paycheck now make up your safety net at 65. Anyone younger than 65 might wonder if there's any point to giving Uncle Sam that money if there's no pot of gold at the rainbow's end. Breaking down Medicare's four sections (part A, B, C, and D) tells another story. Part A, AKA the hospital insurance trust fund, is what you inherit upon turning 65. That pays for the kind of inpatient, overnight care I discussed in a recent episode. Part B is health insurance for all the usual medical work you can think of, but you have to sign up and pay a monthly premium to get those benefits. Part C is a bit of a zebra among the horses because that section of Medicare makes deals with insurance companies to sell private coverage. Last but not least, part D is for drugs. Because of these choices you have to make, do not take your foot off the gas pedal at 65 for healthcare or anything else. Each section has different funding streams, but income taxes are the overall support beams. When the government says that Medicare's becoming insolvent, part A (i.e. the hospital care) is the specific area that's running dry. Parts B and D are within a different trust fund supported by taxes and premiums from its members—both those programs are projected to stay in place for several decades. That doesn't mean they're invincible, but government accounting can be flexible. Math works differently for federal entitlements.Let's think about a classic equation: revenue minus costs equals profit. A regular business can't lose money forever unless they have unlimited cushion from a venture capitalist or institutional investor. Medicare's hospital insurance (i.e. part A), among other parts of the government, can ignore this. Part A operates on a ‘paygo' basis, meaning that every new expense has to be offset by revenue at some point. This is similar to what the government tried to do with major bills like the $1.9T American Rescue Plan. The taxes Medicare brings are credited to the US Treasury as government securities (like bonds) that sit on the trust fund's books and generate interest. When inpatients get their benefits, the treasury makes the real payment and then Medicare writes off a corresponding amount of their government securities. All is well when payments stay below taxes and interest income. That doesn't happen very often. From 2008 thru 2021, there have been only three years where Medicare part A had a surplus. Medicare then redeems bonds to plug those multi-billion-dollar holes. But what if there are no accessible government investments? The treasury has to keep borrowing to make up those gaps for Medicare alongside the rest of our country's needs. It turns out that Medicare can't escape a different but also timeless bit of math: equity equals assets minus liabilities. Because of this, insolvency happens when an entitlement can't pay benefits with tax revenue, interest-bearing assets, and redeeming bonds (i.e. the ratio of asset reserves to annual program costs goes negative).For now, let's step away from the finance. Insolvency is no revelation: the government publishes their historical Medicare insolvency projections. Why is hospital insurance going through a near-constant state of money trouble? Overall demand for healthcare is rising faster than workers can pay for it with taxes. More of our population is elderly and needs extended care. The economy plays a role too—weakening GDP expectations invites more unemployment leading to less payroll taxes. The government already borrows heavily and can't add more reserves to Medicare part A forever. In order to keep back insolvency for a while longer, Congress may adjust taxes and budgeting, Medicare could reduce physician fees, or a public health transformation needs to happen. But since Congress has trouble agreeing what today is, and given the fact that our country is getting older, major change is slow. That being said, Medicare won't disappear; that's not what insolvency is. If the worst comes to pass in 2028, inpatient benefits would fall 10% through 2046 and then 20% through 2096. There is no Social Security Act provision declaring what happens next; at this time, the treasury can't use general revenues (i.e. giving the money directly rather than paying interest on bonds) to cure the shortfall without legislation. Patient benefits and physician payments would be delayed. The rest of Medicare that enrollees sign up for remains the same. Medicare's hospital insurance and SMI fund combined will still grow from 3.9% of GDP now to 6.2% by 2046. There are ~64M seniors on Medicare today, and those using parts B and D pay $204 a month on average for those benefits. The government also has more latitude for allocating taxes to backstop the fund, but the Congressional Research Service estimates that personal and corporate income tax dollars would need to climb ~20% to maintain the current share of part A/B/D contributions. The Social Security Administration's 2022 report details these outlooks a bit more—that source among others will be on my page at rushinagalla.substack.com.There's no shortage of politicians and economists throwing possible solutions at the wall of Medicare's problems, hoping one will stick. It's easy to look outward for proposals, whether they be from our elected officials, hospitals, physicians, or pharmacies. Fiscal policy can help bridge the funding gap but the unintended consequences of changing our tax code or budget might a cure worse than disease. Keeping physician and hospital payments below inflation just incentivizes our country's providers to shun Medicare patients, who may get sicker due to deferred care. The young have to budget even more now to compensate for reduced benefits in the decades to come. You get the idea—the externalities go on and on. Not to mention that medical conditions can be out of our control. Let's still accept those facts, but work to improve ahead of an obstacle rather than be a victim of it. We human beings have incredible adaptation skills. There's no reason to let ourselves grow old and be resigned to withering away. Unpopular doctors tell you to eat well, sleep more, and move more. They're correct, but that framing doesn't work. People respond to incentives. Think of it like this: spending a little time every day to eat better, sleep better, and think better will cut your future Medicare premium and liabilities by $X. Now patients can create a positive butterfly effect helping both themselves and their fellow Americans in old age with a less-strained medical system. Enough big-picture stuff. At the ground level, doctors are trying to reach more patients and streamline medicine by using more physician assistants and nurse practitioners. Is this good for your local healthcare? You'll find out in next week's pod. Stay tuned and subscribe to Friendly Neighborhood Patient for all the healthcare commentary you need. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Sailing your own ship is harder than it looks. The world of medical insurance can feel like an unending ocean of choice and complexity, especially when you get a new job, age into Medicare, or turn 26 and thus can't stay on your parent's coverage. Every ship captain needs a helmsman, so I want to pass along learnings from my own search about how a broker can be a major help and hindrance for picking the best possible health plan. After today's pod you'll know why (and why not) to use a broker.The point of an insurance broker is to help find a plan fitting best with your situation. Health plan brokers, who are licensed in each state they practice at, give you quotes, walk you through all the complicated terms, and explain the final choices in detail, among many other responsibilities. These professionals help both employers and individual patients buy coverage. Most brokers specialize to some degree. For example, your local broker might only help patients with Medicare options (Medicare is complicated enough that such arrangements are necessary). You might hear someone use broker and agent interchangeably. That's a major point of confusion for many patients. Health insurance agents have agreements to promote and sell only one company's plans. A company like United Healthcare of course has a zillion different health plans, but you'll still have less options presented to you if working through agents. Brokers can tag in with however many plans they wish. According to the Zippia career search website and data from the Bureau of Labor Statistics, there are ~140k agents, and ~160k brokers in the US. Both are more likely to work for a private than a public firm. In any case, you don't pay these people directly—both kinds of healthcare shoppers get commissions from the insurance plans themselves. We'll spend more time unpacking how a broker's incentives affect you a bit later, but first it's critical to know what brokers will ask during the shopping process.Your broker will probably check if this is your first time getting health insurance and if you're covered or not at the moment. There should be at least a general discussion of your health needs—how often do you need to visit doctors and specialists? How attached are you to your current providers? Are you taking prescription drugs? Are those medications branded? These medical-focused questions will be similar to what you'd ask yourself when reviewing health plans as I've covered in past episodes. There will also be plenty of time spent on outlining a budget and how many dependents need to be managed as well. If you're not getting insurance from an employer, then your broker can help shop for a plan on what's called an exchange. This is a state-run platform or federal site (like healthcare.gov) to buy coverage from. Some brokers can recommend off-exchange plans as well in a similar fashion to an off-market real estate deal. No matter where you buy plans, a broker should also help translate Summaries of Benefits and Coverage (SBC) documents, direct you to specific insurance support people, and confirm your drug benefits (if applicable). All the info I mentioned so far is not by any means an exhaustive broker-patient checklist but it should be a reasonable foundation. Whether you meet a broker for the first time or are going it alone to buy health insurance, use those prompts and guidelines to make the process efficient and smooth. Regardless of whether a rookie or master shopper is on your side, there are a few guidelines to have a great relationship with that person. A better agent or broker gives you more than just a quote. Because there are so many choices for plans, your broker should make side-by-side comparisons simple. Health insurance shoppers' jobs are not finished after you buy coverage. Agents need to help you with renewal and customer service as needed. If you're getting a plan from a company like Aetna, make sure to get contact info for the matching service rep who can answer your billing and coverage questions.If that all sounds complicated, that's because it is—there's a reason brokers have jobs. Buying insurance is convoluted enough that major exchanges have people called navigators. These staff are kind of like agents but are paid by state and federal grants instead of insurance companies. Navigators aren't required to be licensed in all states and can't promote one health plan over another. Think of these people like the information desk staff at the mall or hospital. I'll link a useful table explaining the differences between navigators and brokers on my post at rushinagalla.substack.com. Now that you know what makes an effective health plan broker, how do you find one? Agents don't show up at the front porch. The best place to start is asking your personal connections, but your state's insurance commission or online platforms like eHealth Insurance are helpful as well. Website solutions may be health insurance company pages, broker platforms, and purchasing alliances (which are employer-insurer liaisons offering packaged insurance for one consolidated fee).As I mentioned earlier, you don't (in most cases) pay brokers directly. The economics of selling health plans is the largest con for hiring a shopper. Companies incentivizing brokers to offer certain plans sounds okay on its face, but there's a transitive property here—brokers are paid by insurance plans, those commissions are reflected directly on insurance premiums, then employers (and by extension you) pay those higher premiums. Agents representing one insurance company tend to get other bonuses as well. Even brokers fielding dozens of plans may bill large clients separately for specialized advice. A rational broker will offer a plan with the highest bonus to them. This is a straightforward conflict of interest similar to pharmaceutical companies in the old days giving overt kickbacks to doctors prescribing certain medications. Employers and patients won't know insurance pricing breakdowns unless they ask. So do ask for the fee schedule of whoever you end up hiring. Quotes for health plans themselves are not final to begin with, since most companies say their estimated premiums are ‘representative.' You only discover a true cost once the official insurance application and underwriting finishes. There are more transparent and independent brokers now who get paid only by patients and employers, but these deals are made for larger clients.Regardless of the misaligned incentives, brokers are useful if nothing else for walking you through health insurance's foreign language. A number of Americans still don't know what a deductible and out-of-pocket-max are. I started this podcast to help spread the word about these concepts among other topics, but a friendly broker can help bridge that insurance knowledge gap for you. Just don't lean too hard on them—remember, they fight for the health plans' money, not yours. There is nothing stopping you from going it alone. In hiring a broker, you're effectively making your final health plan more expensive in exchange for personalized guidance. What matters is that you know this tradeoff exists. Let this knowledge put you ahead of other patients and employers. If you do choose a broker or agent, let them do their job. Take recommendations in stride, but know that neither kind of insurance shopper can represent you. You or your employer are the final arbiters of what plan to use. A broker simply turns your many choices into plain English. Stay focused on making sure that's all your broker is doing. You have the freedom to accept or reject insurance, but you won't fully control the money in the health plan's coffers that makes coverage work for all their members. Unfortunately for our fellow Americans on and preparing for Medicare, funds are running dry. Next week's topic will cover Medicare's pending insolvency and outlook for what Americans can and should do about it. Subscribe and stay tuned to Friendly Neighborhood Patient for more medical field insight. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

You're awake most of the time when getting medical care. But the future is a funny thing. It's not a given that you'll be able to speak or even write your healthcare desires tomorrow or in 20 years. Advocating for yourself is difficult when you get incapacitated or can't think and act clearly. If you're in a coma or become unable to make decisions, someone else has to act on your behalf for many items like money, last wishes, and health. On the medical side of things, patients can avoid these confusing and traumatic situations by picking a healthcare proxy. Today's episode isn't legal advice at all, but I do want to offer some background on preparing for the worst situations where you need someone to know your healthcare preferences through and through.If you can't talk, write, or move, someone else has to carry out your healthcare wishes. This is where a healthcare agent or proxy comes in. Family members don't always take the wheel for driving your care because every state has its own rules. A healthcare agent picked ahead of time in writing is entrusted to make your medical decisions if you're down and out. Some help from a lawyer makes this setup possible. You've probably heard of a common document like a living will. Healthcare proxies are in that mix as well. A living will includes many nonmedical items, but also states healthcare wishes, including directions for what to do about life-prolonging or life-ending care. A healthcare proxy on the other hand involves a named person to make healthcare decisions in the event a patient can't act for themselves. ‘Advanced directive' is the term covering those instruments. A finished advanced directive usually has both the wishes laid out in a will and the persons named as health proxies. Patients can revoke them if changes need to be made for a proxy or specific medical desire. Bringing a written document to your doctors with healthcare wishes and designated agents leads the way for a clear medical direction. The earlier this is outlined, the better. If you get a will, healthcare proxy, or some combination, give that completed info to both your primary doctor and whoever's managing your hospital care if necessary. The major situation to avoid is a patient becoming incapacitated and the physician asking the family what the patient would want, and then getting no answer.So how many people use these legal tools for medical needs? To find out, the Health Affairs journal reviewed ~150 past studies of US adults with a completed living will, healthcare power of attorney, or both. Based on a sample of ~800K adults' medical chart notes, the authors estimated that 37% of patients had completed advanced directives. The event behind this study and similar efforts was Medicare's 2016 decision to reimburse physicians for advance care planning and counseling. If choosing a healthcare agent and having written-down last wishes matters so much, why aren't that many people getting them set up? Not all advanced directives are thorough and some doctors may not be on board for them. It's great that patients can make contingency plans in one place, but writing healthcare wishes on a napkin isn't good enough. According to the American Bar Association, advanced directives usually require two adult witnesses. Each state has its own rules and in some cases these documents need to be notarized. Having a lawyer whip up a living will can be $500-$750+ depending on the state. That's a significant expense for many families. Not everyone needs healthcare proxies or medical wishes—healthy patients don't usually plan for their demise. To adjust for these realities and affective forecast errors, the study authors plotted how many adults within major disease groups completed advanced directives. Patients with issues like heart disease, cancer, and neurological problems tend to exceed the national share of adults with finished advanced directives. That figure and other sources in this pod will be on my post at rushinagalla.substack.com. Given these facts, it's possible to think of living wills and healthcare agents like insurance. You may not use it, but if you need to, you'll be happy that it's there. Having a healthcare proxy knowing your clear medical desires also saves providers time in executing treatment, which saves money.Let's assume that you know exactly what should be done for medical care if you're incapacitated. You'll still need an agent that everyone can trust. The best times for thinking about getting a proxy would be as a patient ages, when a major life event happens, or if a serious illness gets diagnosed. Healthcare proxies are expected to speak for the patient's wishes, have access to said patient's complete medical record, and collaborate with various providers. Most hospitals and clinics follow HIPAA guidelines for privacy—upon choosing a proxy, you'll have to add his or her contact info to your health record. Family, friends, and peers of a similar faith are candidates to start with. Regardless of who you choose, make sure that person is decisive. No other character traits for a proxy matter nearly as much as quick-thinking and knowing your wishes by heart.If you remember nothing else from today's episode, know that a proxy is linked to a person, and a will is linked to wishes. Every patient has different needs and situations. It's a personal choice to build contingency healthcare plans, but more patients should be informed of all the pros and cons to make better decisions. Having someone by your side when life doesn't go smoothly is a plus, even if that person isn't legally representing you. Another useful kind of agent to have at your side is a health insurance broker. American health plans, among many other parts of our medical system, are complicated. I've spent a bit of time walking you through health plan concepts in past episodes. That basic knowledge is still crucial. In the next episode, you'll know how an insurance broker matching up with your aims goes a long way to finding the best coverage possible. Stay tuned and subscribe to Friendly Neighborhood Patient for all the goods on ground-level healthcare topics. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Sometimes patients need to see the doctor more than once a year or even for more than a few days in a row. When a hospital trip comes around, you'll need to pack more than just your clothes and a toothbrush. After this episode you'll know the differences between inpatient and outpatient care as well as how to prepare for any long or short healthcare journey.When thinking of how to get medical care, you're probably imagining a visit to the doctor's office or a telemedicine app. In any case you're in and out the same day. That's outpatient (or ambulatory) care. You can visit a hospital for regular office care—think of how a square is a rectangle (i.e. getting outpatient care anywhere) and how a rectangle isn't always a square (i.e. inpatient care nearly always occurs at the hospital). Regardless, spending more than one night in that kind of facility means you're an inpatient. Most patients don't wake up wishing to go to the hospital. Inpatient medicine happens when you're admitted for an emergency, planned care ahead of time, or for a particular service like childbirth. In any case, you get a bed and room with around-the-clock monitoring. Once the doctors and staff feel that you don't need more care, the discharge process begins. When you leave the hospital, the discharge notes should have instructions along the lines of getting medications, following up with your usual doctors, or miscellaneous guidance. A bit later we'll dive into how you can be 100% ready before, during, and after inpatient care. Knowing the actual scope of inpatient versus outpatient medicine gives necessary perspective.More people are going to the doctor's office for less than a day than others staying overnight or longer. Although knowing the split between outpatient and inpatient care remains imprecise, McKinsey and Company analysts provided some insight. That company reviewed ~$490B in 2016 commercial insurance claims then analyzed that dataset in 2020. The results showed 62% of those dollars being ambulatory, 11% as inpatient, and 27% as mixed-setting care. However, the insurance claim volume behind the money tells a different story. 97.4% of the claims were ambulatory and just 1% were inpatient-related! That disparity in costs between healthcare settings affects the whole country's purse.Hospital expenses take up ~31% of America's annual healthcare spending—that's $1.2T out of $4.1T. Based on 2020 data collected by the American Hospital Association, there are ~33M admissions per year, which is around 10% of the US population. What's the point of these stats? Patients should be vigilant when they need inpatient care because a little guidance improves the odds of a successful hospital trip.A typical, same-day trip to the clinic usually involves costs for procedures, lab tests, in-office medication, and the doctor's time. At the hospital you have worry about those items and more, including medical equipment, administrative costs, nurses' time, specialists' time, more intensive medications, tests, and boarding. It should be no surprise that health insurance companies want you to avoid this. Health plans have a couple incentives among many: 1) to cover preventative care screenings (barring a deductible) lowering the odds of an expensive inpatient trip later and 2) requiring more permissions/authorizations to cover inpatients. When picking health insurance, keep hospital coverage in mind, especially if you don't need more than a couple routine visits and labs per year. If you're not visiting the hospital for an emergency, your doctor is probably doing the formal work to admit you. Although Covid had other ideas in 2020 and 2021, most patients get an elective or direct admission. Elective care involves you going at a specified time for a known condition. A direct admission is your doctor arranging your stay directly per their recommendations. Sometimes you might need to go in advance for lab tests or general monitoring for an issue like a heart or lung condition. Because hospitals tend to have specialized equipment and facilities, certain procedures are only possible in an operating room. Feel comfortable asking your regular doctor what kind of admission to expect when inpatient care is needed.Having a better inpatient experience involves a few helpful tips beyond the usual prep I've mentioned for outpatient care in past episodes. Before any hospital stay, a simple packing list is a great start. Besides the minimum of phone/wallet/keys, do bring emergency contact info, all insurance cards, and your primary doctor's office and fax number. For the medical side in particular, get a written list of medications, allergies, past surgeries, and known family history of conditions in order. Your doctor may forward this EHR info ahead of time. If nothing else, make sure your meds are updated. Inpatient physicians need to make quick decisions for you. Missing drug information alone can be the difference between a shorter and longer hospital stay. In the hospital you'll see more than just doctors and basic staff. Nurses spend a ton of time administering medications, contacting other staff, checking vitals, and prepping you for procedures. Most hospital physicians do rounds throughout the facility to check on the inpatients. Other doctor-extension staff like physician-assistants and nurse practitioners are present as well. Social workers and hospital administrators round things out. While you're getting settled in a room, ask your nurse what the doctor's visitation hours are and who your case manager is. Case managers track your overall stay. After all this preparation, let the hospital staff do their job, but do ask them questions along the way as needed.After the care itself, you have another step to finish before the hospital journey is over. Staff must officially discharge you. Inpatient discharge handouts include why you were at the hospital (or whatever your health issue was), the next steps for care (i.e. getting medications, following up with someone), and why you need to do those steps. Contact your case manager ASAP if you don't get a discharge note with those aforementioned points. Also double-check that your primary doctor is getting any forwarded notes and lab results. You could access your EHR to move everything directly instead. Be thorough so you don't need to return. Just because you leave the hospital for a given condition doesn't mean you get an automatic one-year pass to go back for help with the same issue. Unnecessary re-admission is a risk all patients should work to prevent with the help of their providers. The clinical resource website called UpToDate offers a few a more checklists both doctors and patients can follow to avoid re-admissions. Besides a complete discharge handout, you should have clear, written points on how to get home, what family members to seek for assistance, knowing if your home is the best place to rest, a plan to get medications, and outpatient follow-up. Before going home, let the staff have you explain the major discharge instructions back to them. This final step raises the chance to prevent unnecessary inpatient care.There's no doubt that inpatient medicine is complicated. In reality, you won't always have time or a clear mind to make decisions on any kind of healthcare. It's hard to make smart choices when in a coma or cardiac arrest. Patients can avoid these problematic situations with a healthcare proxy's assistance. Next week's theme covers the pros and cons of having someone manage your healthcare when your ability to choose disappears. Subscribe and stay tuned to Friendly Neighborhood Patient for more healthcare system insight. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Two doctors in the same field have equal years of experience with similar expertise about your condition. Assume you can choose either without needing to wait longer for the other. Does it matter if one of them cares a bit more about you as a person? The answer might surprise you. After this episode you'll know how much emotional intelligence your physicians have on top of their medical intelligence.It's easier to judge a doctor's abilities over a long period of time. If an orthopedic surgeon has done a few thousand knee replacements or if a dermatologist has been seeing melanoma patients for over 30 years, you can be reasonably confident that such professionals are solid at their job. This skill isn't obvious during a random moment in the clinic. In the exam room, however, you can see a few things. The doctor looks into your eyes without typing away on a laptop. The doctor gives bad news about a diagnosis without a soft landing. The doctor listens to your story without interrupting. You might get shamed for being unhealthy. The doctor may encourage you to be active in medical care. There are thousands more interactions showing if your doctor cares about treating a disease as well as treating you, the patient. Immediate behavior gives away much of the doctor's emotional intelligence that a years-long body of work on paper can't explain. What is emotional intelligence (or EI)? It depends who you ask, but in the realm of medicine, EI matters for providers acting based on controlling their emotions, having empathy for a patient when needed, and being aware of their responsibilities. Coaching in sports is a simple but comparable example. Coaches have to adjust their approach based on their players and game plan. How coaches use players and execute a strategy is skill-based. However, interactions with the players have to vary. Some players need to be yelled at to make progress while others are better left alone.In the exam room, certain patients want to participate in their care. Other patients want to just be in and out of the clinic to follow the doctor's instructions without a second thought. Some patients like paternalistic doctors and others want an equalized discussion. Physicians noticing these subtle preferences personalize care for their patients to a new and practical level.Bedside manner is not a new concept in medicine. Johns Hopkins' first medical chief, Dr. William Osler, cared about physicians managing their behavior as well as treating both disease and patients. Dr. Osler's The Principles and Practice of Medicine, which brings up some of these subjects, was published in 1892! Dr. Osler didn't forget about science. The evidence-based medicine we have today is due to his belief that medicine needed a rational and consistent scientific basis. These (at the time revolutionary) ideas led to his famous quip that “practice of medicine is an art based on science.” Doctors are supposed to be patient-focused and not just locked into treating a condition. No surprise there. That being said, there's a massive difference between a clinic saying it's patient-centered, and being patient-focused in reality. There are few moments among many revealing much about the doctor's character and attention for you.As a patient, ask yourself a few questions to help estimate a doctor's emotional intelligence. Are providers being polite with you but with not their staff? If you are due for a hard diagnosis, does the doctor callously lay down the bad news or does the doctor ease into the next phase of your care with grace? If physicians make a mistake, what do they do next? Is the doctor only telling you things to do, or is there some room for collaboration? There's another important question besides asking if the doctor has a competent treatment plan in mind. Are you being heard? You can only find these answers during and after your time at the clinic. An online search may spell out a doctor's track record, but there's no scouting report for situational awareness.Emotions can be imprecise, but that didn't stop a few Indian researchers from conducting a 2018 study in Chennai to measure emotional intelligence. A sample of medical students addressed prompts based on socio-demographic backgrounds, private versus government education, a special EI self-assessment test, and hypothetical situations a doctor may encounter at the clinic. The researchers built their own EI scale ranging from 0-160, with 160 implying that a doctor is the saint of empathy and master of emotional control. The medical students' average grade was 107. Here's the problem—it's hard to screen prospective doctors for emotional intelligence because the participants being tested will report themselves as self-aware and in command of their behavior. Beyond that fact, medical exam scores weren't compared with each student's EI result to put the results in context. Empathy can never make up for bad medicine. If you're having surgery or a complicated procedure, the doctor's skill with a scalpel and stitches matters way more than any kind of social awareness of your pain. It's better to have a trained but mean surgeon rather than a kind but worse surgeon. Even for regular office visits, the doctor's treatment and your response to that treatment will always be the main factor of a successful medical relationship. This Indian study's methods were flawed. However, the results showed (anecdotally) the most common positive and negative payoffs of solid emotional intelligence. I added a screenshot of the study's useful framework on my Substack post which you'll find at rushinagalla.substack.com. Emotional intelligence still matters to patients regardless of how ambiguous it may be. Bedside manners are necessary for higher-level care, but seasoning is no replacement for a dish. Good seasoning improves a meal, but not having a main course, meaning your doctor's lack of actual expertise, means you stay hungry or unwell.Don't wait for a provider to realize they need to treat you as well as your disease. Patients can prompt the doctor to care a little more about them. If the physician didn't introduce themselves to you, ask their name and more about their overall role in the practice. Request the doctor to listen for a moment without typing on a laptop at the same time. Some patients need tough love and paternalistic advice, but it doesn't hurt to ask for being a larger participant in your care. Make sure your expectations of care and the doctor's expectations of treatment line up. Don't hesitate to ask questions like you would for any typical visit, but do so to have your doctor explain a little bit about why they're choosing a particular treatment or assessment for you. All of these prompts help your doctor adjust their care to your preferences.Bedside manners in medicine are usually figurative, but sometimes a doctor indeed sits next to your bed. Physicians apply their knowledge and emotional intelligence anywhere, but their assistance changes if you need medical care for one day versus one week. Whether you are at the clinic for a few minutes or staying at the hospital for a few days, the next pod will tell you exactly what it means to be an inpatient and outpatient. Subscribe and stay tuned to Friendly Neighborhood Patient for all you need to know about partnerships in medicine. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

America has severe doctor supply and demand issues, but the truth is we actually do have enough doctors. How is this possible? After today's episode you'll know how our medical system's resources are misused and what our country must do to improve long-term medical capacity. The patients who understand this will be able to hold the necessary players accountable to make lasting change.If the US healthcare system is a chessboard, and providers are the game pieces, America is playing those pieces with just one column and row instead of using the whole space! Several journals, economists, and medical professionals are on the record for saying that in the next 10- to 20-plus years, physician supply will be dangerously low. They're 100% correct that supply won't meet demand as we know it, but the reasons are flawed. Alarmists have been complaining about doctor shortages for decades. Physician retirement and burnout can't fully explain the current forecasted gaps. The physician shortage everyone worries about remains instead a grand misallocation of our resources. Before moving forward, we have to understand the true influences of physician supply, demand, and then how those two elements change based on population-wide trends.So how many doctors are out there? There are just over one million licensed physicians. According to a census run by the Federation of State Medical boards, the number of doctors grew ~20% from 2010-2020. Most of that growth (+168k physicians) is attributed to new graduates. In the same time frame, the US population rose ~7% to ~330M. It seems that doctors are better than keeping pace, but those headline numbers are misleading. Not all doctors practice the same amount of medicine. Younger millennial doctors seeking work-life balance, late-career doctors, and burned-out providers put in less hours at the clinic. The spread of 2010 to 2020 medical licensees shows the number of doctors aged 60+ grew 48% and those aged 49 and below gained 16%. Are there enough new graduates to replace others getting close to retirement? The number of medical graduates grew ~32% from 2011 to 2021. That percentage sounds nice relative to population growth (~7%), but the absolute 2021 number is small at ~28k grads. The US population is a slow growing mega-fountain while medical graduates/workers are a fast-growing sink faucet. Don't expect both to balance each other without help. New residents, though climbing, remain a lagging signal since it takes years to produce a new doctor. More data gathered by the Kaiser Family Foundation also show the fact that ~47% of licensed doctors are primary care providers (~496k PCPs) with the remainder being specialists. This breakdown suggests that on average, one primary doctor serves 665 people, and one specialist serves 584 people. This is another numerical trick. The doctor-to-patient ratios appear extreme until you learn that most physicians can handle patient groups in the low-thousands. There's a critical difference between real capacity and max capacity. If the US population doubled tomorrow, one average PCP would oversee ~1,300 patients and one specialist would take care of ~1,100 patients. These are reasonable expectations. So why do both patients and economists keep worrying about doctor capacity? Part of the answer is that shortage isn't the same as supply.Physicians don't magically pop into clinics, see patients, and then poof away. Reality shows instead that Amazon.com is better at deliver at delivering packages anywhere in two days than we are with having doctors in the right place at the right time. Our doctor supply needs to be realigned instead of rebuilt. As Covid-19 was picking up steam in 2020, Harvard Business Review made some commentary about necessary supply-side changes to help America reach its max healthcare capacity. The authors stress that hyper-urbanized regions have too many doctors chasing relatively concentrated patients, and in turn rural areas have too few doctors for spread-out patients. Most physicians in private and public settings also work primarily during the traditional workweek—some professionals stuff their patients into a few weekdays. Having additional time over weekends or after usual hours gives opportunities for patients to get care when normal time-frames don't make sense for some demographics. Physicians have to do paperwork as well as see patients, which introduces a brutal time crunch. Having more administrative staff might alleviate some hours for our doctors but the whole cost of the medical system climbs if enough facilities do that. Even if a physician has the availability to see thousands of patients, that doctor can still reject Medicare and Medicaid patients because the payments will be much lower than private insurance. The authors then claim that expanding AI solutions, targeting more patients by tuning availability, and expanding the non-physician workforce (e.g. nurses and physician assistants) can increase each doctor's patient panel enough to keep up with demand. Of all these suggestions, redefining the available times for when primary care office doctors see patients and embracing technology like AI to clean up administrative hassles (i.e. patient charts, insurance claims) are the most appropriate supply-side adjustments we have to make. Of course, supply has to meet demand somewhere; the bigger story behind America's doctor shortage is demand itself running way from our control.US medical care's true needs are what create the shortage in the first place. The Association of American Medical Colleges, or AAMC, publishes a 25-year forecast of physician supply. In their 2019-2034 review, the authors calculated demand based on demographic changes, incidence of diseases affecting those related demographics, and care delivery setting. We know the elderly are growing in number and need more assistance. Care for those ages 65+ takes up 34% of demand now and is estimated to reach 42% by 2034. On top of that, more people are contracting diabetes and heart issues. Those conditions are manageable, but not straightforward. The current trajectory of US medical needs suggests a shortage of ~38k-124k physicians and ~18k-48k primary care doctors by 2034. Those are massive gaps compared to ~28k expected new medical graduates in 2021, but the AAMC lowered both top ends of those ranges by 12-14% year over year from their last report. Why are these ranges so wide and why is the estimated doctor shortage not as bad as the AAMC thought? The report highlights four major countrywide scenarios improving real medical capacity and reducing shortage forecasts. Two of the outcomes are unrealistic and two are practical. These supply and demand futures as well as the other sources in this pod will be on my post at rushinagalla.substack.com.The easy fifth scenario is everything just staying the same. If new medical graduate growth rates and population aging continue, then we get the shortfall numbers I mentioned earlier. The first interesting but otherwise impractical change is all covered patients becoming part of an HMO or ACO insurance plan. In this world, medicine, doctors, and money are vertically integrated like how a company may own its whole supply chain. Based on current US healthcare policy, insurance trade groups, and physician organizations, there would be unending political gridlock to reach this outcome. The next demand change scenario is magical thinking at its finest, but is a helpful reference point regardless. The AAMC modeled what may happen if we all decided work on losing weight, cutting glucose, quitting smoking, and reducing cholesterol. Population-wide health improvements are something we can strive for, but we're human. That utopia is out of most patients' reach. However, the next two possible futures seem a little more reasonable. Drugstores like CVS and Walgreens are sprouting their own clinics. The proliferation of these retail clinics introduces alternative primary care facilities treating minor but acute issues. It's efficient for patients to get basic goods, prescriptions, and routine medical exams at the same place. If referrals to specialists are needed, then patients can still get those permissions and move on with their care rather than waiting too long for a traditional clinician's advice. More registered nurses and physician assistants under strict oversight is another legit overarching trend for plugging the gaps of care doctors can't easily reach. A combination of these scenarios may help to heal Americans faster and keep us from needing doctors to grow on trees.Whatever the consensus definition is for the US's physician shortage, cleaning up healthcare delivery, opportunity, and patient targeting is how supply and demand can rebalance closer to each other. Patients clearly seeing these needs will better handle whatever changes happen next to our medical system. Patients also should know how to judge a doctor's confidence and empathy as well as skill in treating disease. Can your doctor both heal and connect with you? To answer that question, bedside manner in healthcare is the main theme of the next pod. Stay tuned and subscribe to Friendly Neighborhood Patient for all the medical field primers you need. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

You might be wondering: how can a doctor charge several hundred dollars for a ten-minute office visit? Why can the hospital bill $100k for a three-day stay? Who makes up these numbers besides me? Today's episode is going to answer those questions so patients can get closer to what price transparency in healthcare should become.One hilarious irony of medicine is that you won't always know how much you need to pay for a visit and providers themselves don't know how much they'll get paid for the same visit until long after the fact. The dollars on your medical bill are going to be all over the place because of what your insurance covers, doesn't cover, and writes off. However, let's focus on the largest and usually shocking number on the EOB or invoice—the actual dollar amount billed to you or your insurance before any discounts. To be consistent, that top-line figure is called the charge or chargemaster price. The charge is nearly 100% at the discretion of the provider or whoever owns the facility. A general primary care doctor running their clinic might wake up one day and decide that a new patient office visit is $500. Or maybe $50. In either case, that charge is going straight to the insurance company. Charges vary a lot based on arbitrary choices about what providers believe their expertise is worth. However, there are some other factors based on a little common sense that influence healthcare prices.The first major drivers for charges are staff and equipment. Healthcare facilities are more than just doctors and front desk people. Nurses, administrators, and other professionals are necessary inputs for making sure the medical system breathes. Shortages of any given personnel will make the entire system more expensive. The extreme demand for nursing during these last couple years is one such clear example. Equipment quality and depreciation affects charges as well, especially for hospitals and larger medical groups. Getting an X-ray is going to cost you more than guessing if you have a compound fracture or not with a naked-eye glance. Two patients arrive with the same broken left forearm but patient A might have a blood clot or pressure problem that complicates treatment. If patient B has an otherwise unremarkable history, then charges for patient A would likely be higher due to the degree of care needed to deal with the same broken forearm.Let's return to our earlier example of a general doctor charging $500 or $50 for a standard new patient appointment (such a visit might be coded as 99203 for reference). Regardless of the charge, no two insurance companies will reimburse the same amount for the same visit code. Even if you control for the insurance company, the payout still changes based on the individual plan due to how deductibles and coinsurance are spread. Health insurers don't automatically pay the doctor a negotiated fee if the asking charge is less. For example, if the doctor bills $500 for the appointment, the health plan may reimburse $200 and write off $300 (assuming the patient doesn't have a copay or coinsurance). However, if the doctor chooses to bill $50, the insurance will pay $50 even if the negotiated compensation should be higher. Doctors have to overbill as part of this dance with the insurance companies. This incentive, more than any other factor, is why patients see astronomical medical charges. Dr. David Belk, who runs the True Cost of Healthcare website, shows this reality among other medical charge trends directly affecting patients. Dr. Belk's site and the other sources in this post will be on my page at rushinagalla.substack.com. There should be little surprise that providers are charging amounts several times more than what the final payment is. The requirements to get paid vary between health plans. Some insurers pay by the service, by the time, or by the diagnosis. Since these policies vary, providers have to submit all information possible on their claims as well as overbill to claim the max possible reimbursement. And if the insurance company chooses not to pay the doctor, the pumped-up tab is 100% on you.To follow up on this phenomenon, researchers at the Health Affairs policy journal reviewed costs for two portable and common procedures done at most facilities: colonoscopies and MRIs for lower limbs (which are coded 45380 and 73721, respectively). The study's data taken from Mass General Hospital, the University of Michigan Health System, and Vidant Medical Center (Greenville, NC), track the variation in cash fees, private insurance payments, and public insurance payments. The chargemaster prices for each of the procedures were 27% to 24x greater than the lowest respective final reimbursements. These health systems, all of which have a similar bed count, have such gaps between charges due to both patient demographics and overbilling incentives.These eye-popping numbers affect patients' wallets. Even though you may not be on the hook for a full chargemaster price, any increase of that charge will make either your cash payment higher or your long-term health insurance premiums higher. Per conventional wisdom, hospital and office payments across types of plans suggest that privately-insured patients with higher charges are subsidizing the low-margin public and self-pay patients such that everyone is getting the same level of care. The Journal of the American Medical Association debunked this “cost-shifting” with their own review of evidence from the Medicare Payment Advisory Commission. The newest evidence implies that cost shifting does not 100% apply to making up reduced earnings from publicly-insured patients; rather, a rise in private health plan payments go toward dealing with the rising costs of production to take care of that corresponding population. One economic fact about healthcare applying to this situation is that medical offices have mostly fixed expenses. That is, staffing, equipment, and real estate costs have to be paid no matter how strong the business is. Hospitals and large groups notice they get paid more from private health plans and in turn direct that extra money to raise profits while adding higher costs linked to attracting more of those patients. Medicine is an otherwise low-growth business so major providers have to exploit these gaps when possible. Equalizing medical quality for patients isn't part of the equation here. Reality shows that private vs public patients get different levels of care regardless of how payment trends change. Hence, cost shifting doesn't happen unless a multi-millionaire is consistently getting the same quality of care as someone on a low-income plan like Medicaid.Given all this commentary on how medical charges affect you, the last takeaway is that critical events are unfolding right now for helping you deal with the mysteries of billing. The Transparency in Coverage and No Surprises Act are recent laws among many requiring hospitals and insurance companies to disclose certain prices. Changes to come in 2023 make it so various health plans must offer price comparison platforms for 500+ common services and then for all major services in 2024. Although only 6% of US hospitals have been complying with publishing their cash prices as of July 2021, you can still be cognizant of the difference for what providers bill for service XYZ vs what insurance covers for service XYZ, and also be persistent in asking what the charges are.More patients inquiring about pricing are better for our system's accountability. By now it should be no surprise that Americans get sensitive to healthcare prices whether it be for drugs, services, or procedures. There is another certainty. No charges occur if there are no providers. Unfortunately, US doctors can't keep up with the American people's medical needs as things stand now. For the next pod, I'm going to break down the physician supply and demand time bomb that has a countdown much closer than we'd like it to be. Subscribe and stay tuned to Friendly Neighborhood Patient for modern healthcare consumer tips and tricks. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Health insurance is a privilege, but not everyone is so lucky. Even if you have a health plan, you may still get a better deal paying out-of-pocket for routine care. For those who don't have insurance and need to navigate self-pay medicine, this episode is for them.Since 2014, patients have been able to sign up for health plans via the Affordable Care Act (ACA), and the overall number of uninsured Americans fell. However, US adults without insurance remain persistent at between 10-11% the population. Analysis from the Kaiser Family Foundation also covers the reasons uninsured people claim to not be on a health plan. Around 74% of the sample note they're uninsured because they can't afford a policy to begin with. Beyond that, ~41% of uninsured adults disclosed the choice to decline seeing a healthcare professional because of their status. Even stranger, ~25% of respondents said they're uninsured because they have no eligibility for insurance via employment, and ~21% noted that insurance wasn't necessary or desired to begin with. The distribution of choices here is uneven because respondents were able to pick from multiple choices applying to them. I'll have the related figures showing these stats on my Substack post at rushinagalla.substack.com. Regardless of how you feel about insurance paying or not paying for routine medical work, getting emergency coverage is critical given how quickly charges can stack up at the hospital. That's why part of this episode's purpose is to help with managing a cash-pay approach until you are ready to grab that chance to get a proper health plan.So, what can you do if you're uninsured and it wasn't by choice? Being upfront about having no coverage is a good start. Whether you're in contact with a regular clinic or hospital, mention that you are self-pay while transitioning to asking what cash discounts there are. Reasonable savings to ask for when paying cash are between 20% to 30%. To better focus that discussion, ask for a fee range associated with an office visit or whatever particular service you have in mind. But why would a doctor's office give discounts for cash payment? Providers are willing to offer a cash discount if they save the marginal administrative costs from billing insurance. Check if a clinic does interest-free payments or gives benefits for paying in advance. You can also call around to multiple clinics to shop prices if you have no urgent medical need at the moment. However, depending on where you live, it can be sometimes overwhelming to pick a medical office or doctor especially with added stress from not having coverage. In that case, reach out to your state's local insurance department to ask about charity care, community health clinics, and local Medicaid eligibility. Community health clinics are non-profit centers that do routine care—think physical exams, vaccines and preventative care, and women's health—for a reduced cost or no cost. Walk-in clinics and some urgent care facilities may give discounts for self-pay patients if asked. In a worst-case scenario, the emergency room is an option that cannot turn any patients away, but of course it's best to pursue the ER only if needed. Regardless of the final costs, using cash for healthcare gives you more choices for whatever provider or health system you wish to seek because you're not limited by an insurance network.Your health plan is probably not cheap for you or your employer. The insurance company eHealth assessed the ACA's health plan trends from its first open enrollment in 2014 through 2020. Though most Americans get their insurance privately through work, the costs of buying insurance directly from a marketplace are a reasonable point of reference. The math is not pretty. According to eHealth's analysis, 2020 average monthly premiums—meaning the amount you pay for the right to have insurance—were ~$456 per month for individuals and $1,152 per month for families, up 68% and 72%, respectively, since 2014. On top of that, average deductibles—the amount you have to pay out of pocket before coverage kicks in—were ~$4,364 per year with individuals and $8,439 per year with families. These levels suggest that your total annual cost of using marketplace health insurance would range from ~$9,836 to $22,263. The real all-in cost is higher still because these expenses would come before any copays or coinsurance. This is why you should consider, based on your current health needs so far, if such a price makes sense. For example, if you happen to be someone who eats well, sleeps enough, moves enough, takes very few medications, and sees a primary doctor maybe twice a year max for preventative care, you'd probably get a better deal paying for routine care with cash versus insurance. What's the tradeoff? According to Solv Health's pricing tools, the national average office visit cash price at a hospital is ~$300 with the full range being $180 to $675. With the top of that range you are paying just over $1,300 cash for two office visits. If those two appointments were billed instead through your insurance, your final invoice amount would likely be higher because of the deductibles in play and the markups providers add to their charges to create margins after insurance discounts, operating costs, etc. Note that your pharmacy benefits for prescription drugs are separate from medical services.Make no mistake: I am not suggesting that you discard health plans on purpose. If, instead, you happen to be dealing with various chronic issues, quality-of-life conditions, or have an occupation involving risk of bodily harm, coverage makes perfect sense because there is a high volume of complex medical work to be done. The more critical takeaway to make is that insurance and self-pay don't need to be mutually exclusive. Even if you have insurance to begin with, taking a self-pay approach for routine care may save you money. However, following a proper cash-pay approach regardless of being insured, under-insured, or uninsured, depends on how you answer three specific questions. What care do you need (routine preventative care, unusual specialist work)? Will you max-out a deductible or get close? How confident are you of not having a big-ticket service or procedure this year? If your answers to those questions suggest that you will probably spend less on medical care than whatever your all-in yearly health plan cost is, then it's worth contacting local offices to learn the cash prices for routine services like physicals, blood draws, simple imaging techniques, and local outpatient procedures. With all this guidance in mind, patients can trade cash for vigilant but lower-cost preventative care while using health plans as a proper fallback.The tolerance for emergency and general risk is where you draw the line for using cash versus insurance. Another major factor to know is that paying for medical care with cash usually doesn't count towards your annual deductible. You can still call your insurance company, ask what the max allowable charge and ranges are for a given aforementioned service, then compare that amount with cash quotes from shopping around for care. It's also worth noting that due to various price transparency laws passed between 2020 and 2022, hospitals legally have to disclose cash prices and good-faith estimates when asked—be persistent but polite in your search for prices. During your negotiation, using healthcarebluebook.com and solvhealth.com are helpful resources to get an idea of cash prices in certain regions. On the prescription side, goodrx.com is helpful as well for self-pay clarity. If any of you readers and listeners know about other helpful tips for self-pay patients, you're welcome to comment on my Substack post or Friendly Neighborhood Patient's YouTube channel.Alternatives to health insurance besides paying cash do exist, but that will be a theme for another day. Instead, the next episode focuses on the insights for why doctors and hospitals charge what they charge and where the cash-pay numbers come from. Subscribe and stay tuned to Friendly Neighborhood Patient for more on medicine and money. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Just as you would likely review multiple cars or houses before making a final choice, there are moments in healthcare to find another resource for your medical issues. Second opinions in medicine are more common than you think—once we're done with this pod, you'll be able to request for the right kind of additional expertise on time and on target.Even if you've seen the same doctors for long enough that both your and their hair are turning gray, you can and should be comfortable asking for a second opinion in a variety of situations. Not every doctor is going to make a clear diagnosis like how Google autocompletes your search bar. You might think of getting another doctor's advice with a complicated surgery or cancer. For any given condition, you may need to stick with a given care team for a while during the best possible treatment. The most appropriate times to seek a second opinion besides in a cancer or surgery context are when you don't like your providers, you want another specialist to contribute to your care, you wish to review other treatment options, your diagnosis is rare, or if your first-choice doctors have no straightforward approach for handling your condition. However, there are limits: if you're bleeding more than a tech company's stock price you probably don't have the luxury to wait for another doctor to say you're in trouble. There also few good reasons to get a seventh or eighth opinion for an issue—a handful of assessments is better than too many or just one.The Mayo Clinic ran a study long ago on second opinions handled by their own internal medicine doctors to see how diagnosis changes would occur. Based on referrals during 2009 to 2011 from primary doctors outside the Mayo Clinic system, researchers compared initial diagnoses from a referring provider with their own staffs' opinions. Only 12% of diagnoses for the patient sample size were confirmed and consistent with the initial assessment. The diagnosis fully changed for 21% of cases and the next ~67% of cases had some refinements or adjustments. That disparity of medical opinion, even back then, is nuts. This study among the other sources in this pod are linked on my Substack post at rushinagalla.substack.com.Let's use dermatology for a simple example. Suppose that you spend a lot of time in the sun and one day you're worried about a spot on your arm that's been changing colors and size over the past several months. You see dermatologist A for an exam to go over your history. That doctor might say he or she isn't 100% sure what the spot is among a few possible diagnoses but that it's worth your time to monitor that spot month-to-month. You might be rather uncomfortable with that outlook because you're worried about skin cancer and on top of that, scared of needles with regard to having the spot surgically removed and tested. Hence in this case where the clinical diagnosis is unclear and surgery is off the table, you may go to dermatologist B in the next town over for another take. Both dermatologist A and B could be skin cancer experts and have gone to the same medical school but the demographic of patients that derm A sees may contrast with derm B's patients. One of those doctors may also have several thousand more procedures under their belt due to how a practice is organized. Of course, there might be other history that matters for making the correct diagnosis, but in the realm of medicine in general, besides dermatology, many diseases share common symptoms. By that guideline alone, it's wise to seek another provider for input when there isn't any clear-cut answer or treatment. A given field of medicine also can advance so fast that sometimes another provider keeping up with the newest clinical science may have their own take on helping you.Most doctors should feel comfortable with you getting another opinion. In some cases the doctors may initiate the process themselves for getting you referred to a specific provider with the right expertise for your condition. In this context normal referral guidelines apply like I talked about back in Episode #7. Most the time, however, you will need to be in charge of asking for a second opinion. Advocate for yourself without insulting your doctor's skills. That's a fine line, but Yale's medical school and the American Cancer Society's resources offer some great prompts for patients to plant the seed of a second opinion. When consulting with your first-choice doctors, you can ask them to consider what they would do in your shoes. You may ask, “if you were in my situation, which colleague of yours would you seek for more advice?” You could also state that you owe it to yourself and family to make sure all possible options are covered. From a medical perspective in particular, you may also want to ask what other treatment or surgical choices exist, which is a solid transition into requesting an official second opinion. As long as you are polite but firm, you will get enough buy-in from your first doctor that any process to get your important chart notes, labs, and procedure history sent to the next doctor will be easier. In any case, you as a patient have a legal right to a second opinion—some insurance plans may require a second opinion or independent evaluation before significant treatment.When you make it to your second doctor, you should review all possible avenues and risks of treatment. In the case of surgery, ask the doctor what his or her procedure volume is per day and month. You want to have professionals doing 100 hip replacements a month rather than someone who performs a few dozen. No matter what complicated medical care you need, one subtle but critical matter for second opinions is to connect with a professional outside your current health system if possible. Major facilities like Scripps or the Cleveland Clinic hire enough doctors across specialties that getting another person's advice is almost like sending you down the hall for your next class. For example, you see your oncologist at Mass General Hospital but you may benefit from a private oncologist with experience treating your specific condition. There may be some homework required for making sure the second doctor outside of the first doctor's setup takes your insurance or is accessible to you, but the effort to get a clear, independent take on your condition is worth the effort.Regardless of who you see for a second opinion, make sure to bring your recent chart notes, lab results, procedure history, medication list, and pertinent questions. You'll get much more out the visit and the second (or third or fourth) provider will be in a better position to help you. Once you have a productive visit, ask the second opinion doctor to forward new test results and notes back to your main physician so everyone stays up to date with your care. You might believe that all this care is only possible if you have a great health plan or superb connections. That's why next week's pod is going to be about how patients with no (or straight-up awful) insurance and zero connections can best advocate for themselves to get routine care in our current medical system. Subscribe and stay tuned to Friendly Neighborhood Patient for clear, simple healthcare commentary. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Obscene medical bills are just insult to injury when you've already paid a lot of money to fix the injury. After this pod, you'll be able to handle medical invoices with more confidence.You're not the only person who might have a major doctor or hospital bill. Data from a previous review by the Survey of Income and Program Participation suggest that 9% of Americans in 2019 owed “significant” medical debt. In this case, significant was defined as $250 or more. Of those 28-29 million adults who owe that much, 53% owe between $1001 and $10000 in healthcare debt and 13% owe more than $10000. Even wilder, those owing $10000+ are estimated to take up 71% of everyone's personal medical debt—the survey estimates the grand total to be ~$195B. It's no surprise that such balances are considered a leading cause of personal bankruptcy. All it takes is a hospital stay, a few procedures, or even a math error, to run up a five- or six-figure tab. Even if you are paying little bits of an invoice, your medical bill can still be sent to collections which obliterates your credit. This is why I want to go over what to do when you get a fat healthcare-related invoice in the mail or on your phone so you can rise above panic.Knowing the lingo is a great place to start. Let's say you have a simple hand X-ray and the final bill is $1000. Before anything else, you should check if you have a matching explanation of benefits, or EOB. I covered them in a previous episode but EOBs show a full breakdown of the services you had, what the doctor charged, what your insurance paid (or didn't pay), and what you owe. If you lay an EOB next to an itemized statement, you can make sure that a hand X-ray actually happened as well as check if dates and dollars match up. You are within your rights to request an itemized statement with all the charges and diagnosis codes from whatever facility you go to. Now you can look for duplicate items, unrecognized services, unperformed services, and charges that should fall within your insurance coverage. In reality you might have gotten a hand X-ray last Thursday but the EOB lining up with that date might say you had an MRI instead. I know that's an obscure example but all it takes is one incorrect digit of a billing code to throw everything off. With regard to hospital bills, you could reach their billing department then ask if you qualify for charity care or financial assistance and follow-up with verifying if you were billed the “chargemaster rate,” which a service's full cost before insurance discounts. Having these documents ready while talking with a billing representative or advocate in a polite manner goes a long way to getting a resolution for a discount or (in rare cases) forgiveness. There are two major umbrellas of problems when it comes to a medical bill—on the provider's side, the bill could have clerical errors or, on the insurance plan's side, the charged amounts are correct but your insurance coverage is faulty. In any case, you should act fast when you get a hefty medical bill—if you ponder it too long then your balance might go to collections which makes this whole process troublesome. Even then, medical bills should be lower on the priority list than essentials like rent, mortgages, and credit card bills because credit reports aren't as strict about having healthcare debt on the record. Given how complex our medical system is, you could hire a billing advocate or a lawyer to navigate an invoice problem in exchange for a cut of however much you save with their help. Engaging a professional makes sense when you have a lot of varying medical work done like complex visits, labs, and procedures in a brief span of time.However, you as a patient can still approach payment disputes with smart negotiation and prepare to find solutions to a serious bill. For now, we'll focus on how to deal with the provider's side of things to make sure you owe the correct amount to begin with. Besides securing your EOB fast to compare that against your bill, there are some general items you should track at every step. Keep dates, times, and reference numbers for any phone call related to a bill. In writing, document who you speak with, what you talk about, and what commitments or timelines are promised. If you're doing snail mail, get any letters certified. Get clarification on when the bill due date is and when bills may be sent to collections because such deadlines may not match. Each billing department of a hospital or clinic would have a different process for disputes but you can use a website like healthcarebluebook.com to better negotiate common prices for services. I'll link healthcare bluebook and my other sources on this Substack post at rushinagalla.substack.com. Just make sure to avoid medical bill purgatory—this awful place is where customer service puts in a request to their billing team to get back to you someday, meaning never, or if all or part of your bill gets put on hold, which is forever. Make sure to get a timeline for when you should hear back from the billing staff to make follow ups easier. Let's circle back to our $1000 hand X-ray. There are ways to negotiate that down. You could make a hyper-aggressive move by saying to the provider's staff that you are willing to pay $500 right now if the remainder gets written off as well. While it might sound crazy for hospitals to take a 50% haircut, the time saved on their part for hassling you to pay the whole thing is surprisingly valuable. If you happen to have a commercial insurance plan, you could also request to be billed at lower Medicare or Medicaid rates in exchange for paying 10%-20% down now. The safest approach is to say that you'll pay $100 per month for ten months without interest. Most providers are willing to take a payment plan if they have reasonable assurance that you'll take care of the full balance. No matter what you do, get any of those agreements in writing.If you do in fact owe $1000 for that X-ray, the provider could be in the right but your insurance coverage may have fallen short. Most insurance payment denials or reduced benefits happen when you get something that's not covered under your plan, a service that insurers believe are not medically necessary, or when you are no longer eligible with a health plan due to coverage or employment changes. If you call your insurance company or check their website, you should be directed to forms that let you submit an internal appeal. If you saved all your EOBs, statements, and provider billing correspondence, send those as well to help your case. Remember to keep any copies of whatever you send to the insurance. You might get your bill reduced if the internal appeal goes your way. If you get a denial, you can send an external appeal for the insurance to use an independent third party, usually a physician, to review your situation. The decision of an external appeal is usually final. Even though many steps are involved here, your billing journey will be easier as long as you document your conversations and itemized statements. You can also visit the website localhelp.healthcare.gov to have someone assist with appeals. There are other methods out there for escalating medical debt appeals but at that point you may benefit more from having a lawyer or billing advocate take care of the issue.No matter what, my take-home message to you should be that it's better to first make sure that you were billed correctly, then make adjustments as needed rather than get tunnel vision for dodging the debt. If you provide enough evidence for your case and you treat billing or insurance staff well, then you'll get a better resolution to a medical debt issue. Now you know that a healthcare bill is something that you can revisit, review, and change with time. Medical opinions can also be the same way. There will come a time when you go to the doctor and you don't get a clear assessment. That's why the next pod is going to shed light on when you should get a second opinion and what to do if you don't have a straightforward diagnosis. Subscribe and stay tuned to Friendly Neighborhood Patient for more healthcare tips and trends. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

One day you could wake up and your body isn't just having a bad time—all you know is that you have an issue that needs to be dealt with fast. In the US, we have urgent care and emergency rooms made to help for this purpose. Once you know the pros and cons between urgent care and the ER, you'll be able to make better choices when sudden health problems arise.How can patients walk the fine line between urgencies and emergencies? Like I've stated in past episodes, Friendly Neighborhood Patient is not a medical advice column, but knowing the standards of an immediate health need still helps with making a better call. According to the Mayo Clinic among other health systems, the severity of an issue and whether or not you have other pre-existing conditions are part of the major factors in choosing the emergency room or urgent care. For example, two patients could have the same emergent chest pain but patient A has diabetes and hypertension while patient B has no other remarkable problems. Hence one could argue that patient A should go straight to the hospital. In general, emergency rooms provide 24/7 access to physicians, procedures, and high-end resources for dealing with pretty much any life-threatening issue. Urgent care or rapid care facilities are open most days, but not 24 hours, where you can quickly see nurses, physician assistants, and sometimes doctors for common medical conditions that shouldn't wait but aren't worth going to a hospital for. These issues like back pain, bronchitis, minor skin problems, vomiting, etc. are routine in the grand scheme of diseases. However, there is a gray area where certain medical issues seem too minor for an ER visit but are significant enough that waiting too long for help is not ideal.In a perfect world, patients should be going to their primary doctor as the first-line choice for urgent but not emergent problems. The issue is that primary care providers can get booked up for a while and you can't afford to wait a few weeks for a visit. This is the niche urgent care fills. Another huge draw for urgent care is availability over weekends and evenings when most doctors are unavailable, but you might have a strict calendar and still need to be seen in a timely manner. That being said, you should still reach your primary doctor to find out what his or her availability is. Ask for an urgent visit to see if extra time can be made since your main doctor knows your history better. The emergency department chief physician at University of Chicago's med school also breaks down when to go to the ER versus urgent care, and while doing so, makes a great point that both types of care aren't mutually exclusive. An urgent care office can and should push you up to the ER if your condition is serious. Although such a place may refer you to the ER, you still need to be the best judge of your well-being—if you feel that something is seriously off or if there is a systemic problem, going straight to the ER would of course be the wiser choice than doing something more cautious.Another type of facility called a walk-in clinic can help with issues that aren't quite on the level of urgent or emergency care such as sore throat, mild cough and flu, localized rashes, eye and ear irritation, etc. Some urgent or walk-in clinics may do lab tests and x-rays among other clinical work, but patients shouldn't use those clinics for everything. On the flipside, some patients choose the ER for addressing every single issue because such places cannot legally refuse to give care. This is why emergency departments have longer wait times for no good reason draining each state's health capacity. This is why making smarter calls on your immediate health needs helps other patients too. The Scripps health system has a wonderful diagram showing what to consider for choosing the ER, urgent care, a walk-in place, and calling 911. I'll link that infographic on my Substack post at rushinagalla.substack.com. Regardless of whatever place you choose, you should bring three critical items if possible: your medication list, known allergy list, and written procedure history. These resources will make the job of the ER doctor or urgent care nurse much easier.The main factors that matter to patients balancing urgent versus emergency care are severity of the medical issue and the cost to deal with that problem. Convenience matters to some degree as well—there is a reason why providers say you should go to the nearest emergency room during serious adverse events. However, I want to spend a little time on costs before closing for today. Regardless of the medical problem at hand, urgent care would probably be cheaper with consults ranging from a few dozen to a couple hundred bucks without insurance. We all know the ER is more expensive, but hospitals give better access to physicians, surgical resources, and advanced tools that could save your life in a critical moment. Although hospitals can't turn you away even you have no ability to pay, urgent care facilities do have the right to deny care if you have no funds. When it comes to coverage, most insurance companies follow the Prudent Layperson Standard, aka PLS, to determine whether it made sense for you to go to the ER or not as well as how much to pay for the hospital stay. PLS mainly focuses on justifying insurance for “any medical or behavioral condition that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that the severity of their condition would result in death or harm to a physical organ.”That definition is a mouthful, but it serves as our preview to the next major pod about how you can deal with medical bills, whether they come from the ER, urgent care, or a regular clinic. Subscribe and stay tuned to Friendly Neighborhood Patient to add more instruments to your healthcare toolbox. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

There's no doubt that mental health matters but not everyone knows how go about seeking help or even how prevalent these issues are for patients. Soon you'll have more confidence in picking the mental health option working best for your situation.The fact of the matter is that no basic lab or blood tests exist for mental issues. Mental health conditions are primarily diagnosed upon having an exam or long-term study of your health. Even though we don't know all the answers about why our lovely brains can get depressed or schizophrenic, we do know that such diseases happen a lot. According to data crunched by the CDC and National Institute of Mental Health, about one in five adults in the US experienced some kind of documented mental illness. In the last 12 months from the most recent tally in 2020, 19% of all recorded mental illnesses were anxiety-related and the next 8% were depression-related. I'd argue these numbers are probably under-reported because of the stigma in our culture that it's shameful to have this kind of disorder. Spoiler alert—it's not shameful by any stretch of the imagination to deal with those obstacles. Some patients might believe that the only way to deal with such problems is to have medication or do some cognitive behavior therapy. However, there are way more choices than you think and a number of professionals you can seek. Not all shrinks are created equal. Knowing what options are out there is a huge part of taking the first steps in bettering your mind.There are a variety of warning signs that can be a trigger for seeking mental health assistance, but since this podcast isn't a medical advice column, I'm going to link the general list of concerns as noted by the National Association of Mental Illness. That link plus anything else I cite in this episode and beyond will be found on my Substack at rushinagalla.substack.com. Let's say you're somewhere between being on the fence and being 100% sure that finding mental help is the next step. Where do you begin? The simplest way to go about this journey is to look at the actual professionals in your area that offer specific kinds of psychiatric care. The process of finding a mental health provider is similar to how you'd seek a primary care physician but you should have a clear aim for a solution that makes the most sense. In the mental health world, patients can get official assessments, counseling, therapy, medications, or a combination depending on the provider. But then you ask, what if I don't know what I need? In that case, a great first step is to check out counselors in your area. These people could be licensed professional counselors that have a master's in counseling or psychology and do first-line work that other mental clinicians may not be available for. More than anything else, the counseling option gives you a sounding board to help with both reactive and preventative mental healthcare if you're not sure about specific options. On top of that, counselors exist to help with various walks of life—someone could assist with marital counseling and substance abuse. Even other counselors who dealt with mental health challenges themselves can jump in to comfort you. The only significant downside to first-line counseling work is that such professionals might not be able to give an official assessment of your mental well-being. If you're leaning towards getting a concrete opinion and maybe some initial therapy, clinical psychologists are the next level up. These are people who usually have a PhD in psychology while seeing patients to make a diagnosis and provide therapy. If you happen to be in school, certain academic institutions have their own psychologists that connect with you and other staff as well. These psychotherapists may also offer cognitive behavior therapy, which is the practice of singling out negative behaviors and in turn replacing those issues with positive habits. This avenue makes sense for exploring non-medication treatment and getting an opinion without going as far as seeing a psychiatrist. This approach also makes sense when you or your contacts feel that you have a possible mental disorder requiring the kind of attention a counselor wouldn't be able to provide. The next degree of care available to you would be the realm of prescribers such as psychiatrists. These mental healthcare workers are medical doctors who do traditional clinic work for making a diagnosis and offering medication-related treatment. Not all psychiatrists or mental health nurse practitioners may do cognitive therapy but some may instead complement treatment plans with counseling. In a situation where a mental condition is rather severe and therapy hasn't worked in the past, then it might be proper to see a psychiatrist. Getting prescriber-focused assistance would be something to try once the choices along the counselor and psychologist spectrum get exhausted. You would likely need a referral (unless you have a PPO health plan) to see a psychiatrist outside of a hospital setting, but visiting your general doctor is another good first step to get an opinion about your condition before getting put through to another doctor or therapist. A great website to help you find local therapists is www.psychologytoday.com/us/therapists. For psychiatrists, you can visit locator.apa.org. Online platforms like betterhelp.com or teladoc.com are great places to start with as well.No matter who you see or what app you use, you should feel comfortable asking questions just like with any provider, because you need to find out if you can trust your provider's judgement even if you disagree with the diagnosis. The actual weight of getting a mental health diagnosis varies between patients because, again, there are no traditional lab tests with mathematical or chemical evidence showing that you have depression or any similar disorder. Some patients feel a mix of comfort and fear in being able to put a name to the face of their issues. Because mental health treatment is created based on your provider's experience, training, and diagnosis criteria more so than with testing, there is nothing wrong with getting a second opinion—just avoid trying to visit every single therapist and psychiatrist in town.Because mental health appointments like talk therapy, psychiatric emergencies, and cognitive behavior work differ from a traditional medical visit, I want to leave a quick note on the insurance side of things before moving on—mental health coverage is not always clear-cut and not every plan is willing to pay for such treatment. The best way to demystify this is to contact your insurance company to ask what the specific deductibles, copays, and coinsurance look like for a given scenario once you decide on pursuing a counselor, psychologist, or psychiatrist.If a medical problem comes up fast, whether it's related to mental health or not, you should know about the first places to go. The next pod's theme covers the differences between urgent care and the emergency room as well as which one you should pick for a given situation. Subscribe and stay tuned to Friendly Neighborhood Patient to get ahead on healthcare. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Imagine for a second if you could have treatment which fits you better than a tailored suit. In some cases, biostatistics tools and custom medicines like gene therapy open new doors for patients. After today's pod, you'll know all the practical and impractical uses of precision medicine for patients.So what is precision medicine? Aren't doctors already supposed to customize treatments for each given patient's situation? The short answer is yes but the longer answer leaves a key gap I want to talk about. What the majority of doctors follow is evidence-based medicine. This is a time-tested process—a patient arrives to the clinic with XYZ history and suffers from XYZ complications. The provider then suggests the best clinical or surgical options based on what has worked for the disease in the past as well as what makes sense from experience in med school, residency, etc. In essence, treatment is targeted for alleviating symptoms or root causes of symptoms, which is great. Notice that potential solutions are personalized to the given disease more so than the patient directly. That distinct intent is where precision medicine begins. As you may imagine, patients with a given disorder can have wildly different reactions to similar treatment. To be clear, evidence-based medicine has way more benefits than drawbacks—precision medicine has been promoted over the last couple decades as taking care to another level. The greatest benefit patients get from precision medicine is that any treatment you take is created from your specific environment, lifestyle, and genetic makeup. For example, if someone ends up with a disease like lung cancer, there could be a customized therapy targeting the problem with that patient's genome in mind.Although genomics is a huge part of precision medicine today, especially with everything we've learned since the US's Human Genome Project finished up in the 2000s, precision medicine was in motion before then when the textbook Pharmacogenetics was published in 1962 by Dr. Werner Kalow. A helpful article on the Harvard Data Science Review dives more into the historical buildup of precision medicine, which I'll link on my Substack page at rushinagalla.substack.com. Even before the 20th century, doctors were interpreting data linked to the onset and treatment of disease to craft better options. For example, there might be a group of patients who all suffer from severe asthma. Precision medicine could in theory still occur here without going into each patient's genetic profile. In this situation, doctors could see that patients one to 100 live in cleaner-air environments than patients 101 to 150. Maybe patients 80 to 120 have other issues that make the asthma worse or better, and so on. Modelers then crunch and reformat all that unstructured data to suggest treatment for each individual. Obviously, evidence-based medicine isn't going away. If a whole region is dealing with an unusual flu outbreak, we know that making tweaks to the annual flu vaccines will do a reasonable job targeting the specific changes made by that strain of the flu itself without needing to consider every individual's situation case by case. Evidence-based care is still part of the foundation of what precision medicine does. But since in this day and age we're generating so much data and have a better understanding of our genetic code, there is more runway for precision medicine to take off such that patients may someday get one-of-one solutions to their issues.Shifting over to the genetic focus of modern precision medicine shows us that we can deal with patients who respond differently to common treatments. Some patients may need varying dosages, treatment lengths, or alternative choices because of side effects. Having 100% unique solutions for each person's medical issue is wonderful and utopian on paper. The reality of precision medicine's main playing field is cancer treatment, which is life-saving but not cheap. ~90% of precision treatments approved by the FDA in 2018 were for cancer indications. Well-known cancer therapy brand labels like Keytruda by Merck or Herceptin by Roche cost multiple hundreds of thousands a year before insurance discounts. There also could be issues between how customized the medicine is versus whether the patient actually matches up well to do the treatment. Cancer therapies are anything but short experiences—not all patients can handle extended courses even if the treatment is a perfect match for their genes. Not to mention that a skilled oncologist wouldn't be enough to oversee the treatment since there would be considerable expense involved for doing genetic sequencing and reading out results that not all doctors are trained to understand. Not all medical facilities are equipped to perform this kind of care regardless of superb personnel. It's also difficult to do a clinical trial to make better custom medicines in the first place since, by definition, uncommon diseases affect less people so clinical study recruitment becomes a separate challenge. This is part of why the biggest irony of precision medicine is that individual solutions improve only when you accumulate enough data at the population level. There is nothing inherently wrong there, but that's just where precision medicine is at for now.A recent in-depth review by the Brookings Institution think tank offers some insight on how “agile governance,” which is a policy approach for regulators to make better private and public partnership decisions for the purposes of innovation, can bring down precision medicine costs and ease logistical problems. That analysis focuses on aggregating private and public health care data, improving direct to consumer genetic testing incentives, and building international relationships between drug regulators among other possible initiatives to make precision medicine practical.Without a doubt, the medical field is still a number of years away from having consistent treatments with a capacity for individual genetic modifications serving patients at the outpatient clinic level. However, your care can still improve with better decision-making that still takes your social, genetic, and medical history into account so medicine doesn't reduce itself to just a bunch of if-then statements. Another field of medicine that shouldn't be reduced to algorithms is mental health, which is the prime subject of next week's pod. At that time, we'll learn about what mental health resources exist and how to use them well. Stay tuned and subscribe to Friendly Neighborhood Patient for the big and small pictures of healthcare. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

It might seem wild that a doctor or hospital won't take your insurance, especially since more than 91% of Americans have at least some form of coverage. After this pod, you'll know what “out-of-network” really means as well as the choices you have when health insurance doesn't go too far.In strictly financial terms, it's wiser to seek a provider who takes your insurance. You're already paying a king's ransom for the insurance you have so why pay more? In any other context, a doctor accepting your insurance won't be necessarily better than a provider who does not (at least without regard to a given facility's resources). A number of insurance plans do offer a little coverage for seeing a provider who doesn't participate in a given network, but for a good amount of the time, you are going to be paying full price for medical care when going to such places out-of-network. Just for clarity, something is considered out-of-network if that provider or facility does not have a negotiated contract with a given health plan for reimbursement. We'll save the discussion about medical care quality for a longer episode but there are legit reasons why some providers don't contract with health plans. For now, I'm going to focus on what happens with seeing an office-visit-focused doctor who's out-of-network, because getting emergency care out-of-network is another can of worms that's better to open up later. In any case, when you visit someone who's out-of-network, they either bill your insurance for a small payment then bill you, the patient, for remaining balances, or just charge you full price for care out-of-pocket. Doctors who do not accept Medicare or private insurance usually do so for three major reasons: burnout, administrative challenges, and payment issues. Medicare and some private insurance plans have strict requirements incentivizing doctors to check boxes of data and see a high volume of patients. As a result, some physicians want to shift attention back to patients and in turn stay away from spending too much time entering medical data. Some physicians just hire more staff to take care of these necessary evils but the fact remains that due to current law and incentives, most providers are better off in a large group or hospital practice to deal with all the red tape. A doctor who visits several dozen patients a day and needs to enter reams of clinical notes for each person is just a byproduct of volume demands and increased day-to-day admin responsibilities. Hence, some physicians believe that spurning insurance plans leads to better control over both their professional and personal life.In response to the current incentives from insurers and big-medicine organizations, some doctors are detaching themselves from the current system by going fully private with direct pay business models. A successful out-of-network doctor who bills patients directly without any link to a health plan usually has a massive following and unparalleled medical expertise that appeals to enough people willing to pay for that kind of next-level attention. This is why, if you have disposable income, or your healthcare sits high on your priority list, you should be flexible with primary or specialist doctors who may not take insurance plans if they are skilled in treating a particular medical condition you have. If you are willingly seeing a provider who doesn't take insurance plans, you should ask for a quote regarding whatever office visit or service is needed.I do respect that not everyone in the US has a fortunate enough situation allowing them to invest more on their healthcare, but we should remember that even though every physician has finishes years of training before seeing patients without supervision, you shouldn't assume that two doctors in the same exact specialty accepting the same exact insurance plan are of equal quality. You can compare apples to apples or smartphones to smartphones, but comparing one internal medicine doctor to another provider in the same field is not that simple. One of the doctors could have practiced medicine a couple decades longer but the fresh-off-the-boat resident could have gone to a better med school with access to new research and resources. Another doctor may have the benefit of seeing a particular demographic of patients in the tropics versus colder places. There are lot of variables involved since medicine both a scientific and human capital profession.Even though a few out-of-network medical practices are making names for themselves, the hard reality is that few providers can live without insurance plans. Take Medicare for example. According to the CMS's provider database, just 1% of all non-pediatric physicians opted out from Medicare in 2020. And in 47 of 50 states, less than 2% of respective physicians in each of those states opted out. A doctor who opts out from Medicare can enter a direct payment relationship with patients to bill fees above whatever Medicare reimburses for any given service. Although some doctors can keep one foot in the door by having the choice to bill Medicare or not by calling themselves “non-participating,” the handful of providers going the distance to sever themselves from Medicare sail their own ship. Even though it's clear that doctors need Medicare more than Medicare needs them, the greater challenge for patients is that participating, in-network doctors may reject new patients who have Medicare because the reimbursement is minimal. Medicare payment tends to be 80% or less of whatever a private insurance plan reimburses for a given service like an office visit. I'll link the data review done by the Kaiser Family Foundation on my Substack page found at rushinagalla.substack.com.Seeing an office-visit-focused doctor without insurance is a totally different story from getting help by an emergency provider out-of-network. Because most patients don't choose when their emergencies happen, patients tend to leave the financial consequences of an ER visit off their minds till later. You could be discharged from the hospital, your insurance could get billed 100k, the insurance covers 30k but you're on the hook for a 70k balance since the providers taking care of you during that period were out-of-network. This is where the horror stories of crippling medical debt come from. Thankfully laws such as the recent No Surprises Act safeguard patients from getting balance-billed for emergency care at in-network facilities among other venues. Regardless of your need for emergency or routine care, you may ask a facility to give you a “good-faith” estimate of services. Again, when pursuing out-of-network care in general, you should feel comfortable asking for quotes or price ranges. Adding in a bit of fee transparency to in-network or cash-pay healthcare makes us all better off by introducing a little competition with accountability.Another cool topic in healthcare that's getting a clearer look is the realm of precision medicine. Imagine what happens when a given medication is matched perfectly with your genetic disposition. That's cool but this concept has been around for years. In the next pod I'll talk about what's new with hyper-customized treatments and what that should mean to you. Subscribe and stay tuned to Friendly Neighborhood Patient for healthcare economics and other fun themes. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

As a patient, you're beyond ready to get started on whatever treatment you need to heal or prevent other issues. Sometimes though, you get hit with a prior authorization, which is, without a doubt, healthcare's most annoying rug pull. Thankfully, we have simple ways to deal with it.Healthcare is a field where you may consume a given product or service at your leisure but at the same time find yourself stopped by gatekeepers preventing you from getting other routine medical work done. Let's say you go to the doctor's office and get an order for an MRI or a prescription medication for acne. Your insurance plan can tell you that you cannot have either of those orders covered until the doctor gives more info as to why you need them. This process grinding your care to halt is called a prior authorization, otherwise known as a PA. Now you might be confused as to why health plans are sticking their nose directly in care decisions your physician makes in your best interest. From the insurer's perspective, the PA serves to screen for drug abuse, dangerous medication combos, and last but not least, to reduce costs. The logic is straightforward—a health plan doesn't need to pay for a drug if you can't get it in the first place. We'll dive into the incentives a bit later but first you should know more about the process behind the scenes for us to better deal with the problems of PAs.In most circumstances, if their medication needs a pre-certification, patients are left in the dark. When the pharmacy tries to fill a prescription after your doctor makes the order, that is the precise moment where the insurance plan notifies the pharmacy that a PA is needed, and in turn the doctor's office gets a fax or electronic message. This is where your medical care gets delayed, because the pharmacist would say that you need to wait for your doctor to deal with the insurance plan first before your drug can get dispensed. At this point you probably won't know what's going on unless you've dealt with PAs before, so I'm going to pull back the curtain here. A number of medical offices use virtual prescription management services to deal with PAs but there is still a significant amount of manual work required over the phone or fax with the insurance company to prove why you need prescription XYZ or a lab order for ABC. Again, to be clear, this is all happening before patients receive any intended medication or lab work. This is why PAs can take between a day or a month to get approved. The American Medical Association runs a yearly survey of doctors for many topics. PAs are infamous enough to get their own theme. In the AMA's 2021 review on pre-certifications, 93% of respondents noted that PAs cause at least some delays in care and 82% of respondents noted possible occurrences of abandoned treatment due to PAs. These stats are telling, but I'll link a screencap of the survey's original infographic on my Substack post which you'll find at rushinagalla.substack.com.At any rate, the ball is still in your doctor's court to get the PA rolling. They have to send your basic information, every medication for a given condition you've tried so far, and usually a rationale for the particular treatment's medical necessity. On top of that, every insurance company's PA requirements vary with an uncountable number of possible forms that don't talk to each other. In theory, each the health plan is supposed to refer to clinical guidance for applying medication efficacy to PA approval. As someone who's submitted more than a few PAs, I can tell you that it's like a drawn-out and convoluted job application you write on someone else's behalf that can still get denied even if you offer the perfect fit. So now your doctor sends a PA to the insurance. Although the next step can seem like a black box, some PAs get run though algorithms that spit out a decision or a real person needs to go over the evidence at hand depending on the specific order. Going with our earlier example, it's simpler to argue for why a patient needs a specific acne medication versus why a patient needs an MRI or another kind of full body imaging. After taking a while to digest the PA, your health plan gives a yay or nay. If the doctor gets a yay, they will notify the pharmacy or lab and you're good to go.If for whatever reason your PA does get rejected, you or your doctor have a right to appeal the outcome or submit a new, updated draft. PA decision makers include both administrators and clinicians working directly for the insurance plan depending on the specific request. In some cases, the insurance plan or provider can suggest an alternative drug that is covered or something else that should be tried first before the PA succeeds for the original intended drug. As you may imagine, neither of those outcomes would be helpful for every patient, especially if there are significant delays in treatment. The insurance company has the inventive to reach the physician's office directly for PA requests because the information needed to execute the PA is part of a medical record which requires time and effort to access. Another issue with PAs is that you could win a battle and lose the war such that even if a PA gets approved, the insurance still may not cover a whole lot of the cost of a prescription, especially if your coverage has a high deductible. Like them or not, PAs are just a part of the game when it comes to healthcare delivery, but there are ways to handle them.When your provider is finalizing what treatment and orders you need, that's a great time to ask if the suggested options require a PA. If you get something other than no for an answer, you are planting the seed for having the office check if there is a high chance of a PA being triggered. Then if a request comes around, everyone will be more prepared to handle the delay. If you've dealt with pre-certifications before, you can ask your provider if there is documentation that previously worked for approval. Just bringing up the fact that a PA might be needed causes a little Hawthorne effect: if providers know they're being watched by the patient, pharmacy, and insurance plan, they will be in tune with the cost-benefit analysis for any given treatment, as well as understanding the ramifications of any issues with the PA process. Now the provider works a little harder on your behalf to save time for all parties involved because you sprinkled in a little preventative action by mentioning the possible need for a PA.Let's switch gears to a bigger picture topic but still something that impacts your major healthcare decisions. You've probably heard that some doctors or services are labeled as “out-of-network” and have little to no coverage just like you'd find with certain drugs. In the next pod, we'll demystify and learn how to navigate the times when your insurance benefits won't help you. Stay tuned and subscribe to Friendly Neighborhood Patient for straight facts about the medical field. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

One quick way to start arguing with a politician is to mention prescription drug pricing changes. This issue affects everyone, so I'm going to give you the brief story for how drugs get from the manufacturer to your front door as well as go over the underlying reasons for why they cost a ton.We're probably better at tracking drug pricing than remembering to get rid of the trash. For example, if you're taking blood pressure meds that cost $2 per pill per day now and next year each pill costs $2.10 daily, you might have the difficult choice to prioritize savings versus your health. This potential dilemma is why the Centers for Medicare and Medicaid Services, or CMS, keeps a watch on various drugs they pay for and whether price levels are higher or lower than inflation. Economists, politicians, and other insurance plans often reference these data. The most recent analysis by CMS on this was taken from data spanning 2019 to 2020, right before inflation became severe—CMS's review back then referenced inflation as 1%. Thankfully, whoever reviewed the data again in February 2022 put both the Part B and Part D drug repricing in context. For those of us who are not yet on Medicare, Part B just refers to medications that are mainly administered in hospitals or medical offices (such as cancer therapies or infusion treatments), while Part D addresses most of the drugs you'd take at home, like diabetes or acne meds. Prices on 50% of the part D covered drugs and 48% of part B drugs rose more than 1% in the study's period. If we filter down the data to compare the changes against our 2021-2022 inflation, prices for 17% of part D and 18% of part B drugs during the study period rose above 7.5%. Although what I'm going to say next might be hard to believe, drug prices can decrease. Such a phenomenon tends to happen when a pharmaceutical company has an expiring drug patent or if there is serious competition from a product like a biosimilar. For reference, CMS found that 41% of part D and 46% of part B medications had nominal price reductions. That being said, the real magnitude of high-impact drug price changes varies if the pharmaceutical company raises the cost per dose or the cost of the overall medication's flat lifetime, which, as you may imagine, depends on treatment method. In general, the beginning and midway points of the year are when drug companies make significant pricing decisions. The list price of a therapy stated by any pharma company is a proxy for how much less or more you're paying later after discounts. Part of the issue is that drugs are still relatively expensive in the US versus our neighbors like Canada and Mexico, even after insurance coverage takes a lot off the top.Before going into the food chain of drugs, we should know how drugs pop into existence. Because of government orgs like the FDA, pharma companies do time-intensive research to find a potential drug candidate, review its best medium, put it through phase one/two/three trials, and get it reviewed by regulators before market approval. The US government in particular is reasonably strict with drug development and very lax with pricing and marketing controls. I'd argue that lack of both marketing regulation and post-approval drug efficacy review are what set the bar high for prices to begin with. When it comes to a drug for rheumatoid arthritis like Humira, which in 2021 had the most revenue among all drugs not including the Covid vaccines, it's easy to find efficacy data from the company's primary studies but not as simple to find rigorous peer-reviewed long-term head-to-head comparisons between Humira and something like Enbrel which is also used for similar conditions. Most pharma groups like to say that high research and development costs are why prices need to be steep. In March 2020, the Journal of the American Medical Association reviewed medication discovery R&D expenses taken from 2009 to 2018 and found the median cost of a new drug, start to finish, is just under $1B. Years and years of work could still lead to a drug's complete failure. Highly organized trial and error is how the business works. Other factors besides the development itself that raise or lower prices include competition, efficacy and safety. Patents also extend the lifetime of this pseudo-monopolistic pricing, which is why generic drugs for a given condition are less costly than brand-name choices. However, the Covid vaccines or monoclonal antibodies are recent and helpful reminders that we need consistent medical therapy innovation. Hence, pricing is something government and industry should mitigate rather than punish. I'm fully aware that's easy to say and hard to execute, but all the info we covered so far begins to inform us on how drugs move from the factory to our local pharmacy.The first stop in a brand-new pill's journey leaving its manufacturing plant is a wholesaler. These are the first bulk purchasers for the medication where the “average selling price” comes into play. Then pharmacies and hospitals buy from those wholesalers for what is called the “actual acquisition cost” to dispense the drug for patients later at the “cash price” before coverage and benefits. I'll post a helpful info-graphic from the site US Pharmacist that shows this supply dynamic on my Substack page found at rushinagalla.substack.com. Because the wholesalers are businesses as well, they will sell the bulk drugs at some premium. Of course, when it comes to US healthcare economics, there's a curveball here. That curveball would be the fact that you, the patient, are not the true end purchaser. This is because most insurance plans use pharmacy benefit managers (PBMs) to negotiate in secret the lowest possible prices. Medicaid and pharmacy benefit managers in a few states do impose price ceilings for certain drugs, but a drug's price on any given day varies based on who's paying. The best way to see this logic is by pretending that you mow lawns in a neighborhood. You're going to charge a different rate for the lawn owners in front of a mansion versus the lawn owners in front of a shack. Pharmaceutical companies also give rebates to benefit managers to win a better placement on an insurance plan's formulary, regardless of true efficacy. Going any further demands another episode by itself, but the main takeaway I'd like you to have is that drugs get priced as they are currently because they pass though many hands before getting to you and the facts of true effectiveness get shrouded in mystery. Collaboration, rather than division, between government and the private sector as well as innovation with medication data transparency are the next areas to reach common ground on drug prices.With that done, let's get away from the bird's eye view and think about the day-to-day for a moment. After going to the clinic, your doctor whips up the perfect treatment in mind for your medical issue and there's a particular drug you need to string everything together. At this moment, a strange and way-too-official-sounding obstacle called the prior authorization prevents you from getting past the starting line. Going over why prior authorizations happen and how to deal with them is next week's theme. Stayed tuned and subscribe to Friendly Neighborhood Patient for more commentary on the medical world. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

You should treat your medical records with care just like with your keys, wallet, and phone. Hopefully, medical providers are treating your data even better. By the time we're done today, you'll know about health record protection as well as how to use those records properly.When you see your doctor and their scribe typing furiously on their devices in the exam room, they're trying to update your medical record, which includes things like your basic family health history, surgeries, meds, lab results, visit notes and more. It's a great idea to keep an electronic or paper copy of such data for yourself. Why? Because the records being kept at your primary care doctor's office may not sync up with the record that a hospital or your private specialist uses. Before rushing into the specifics for getting a hold of your health record, it's more important to know a few simple terms and the background of why people get all up in arms over laws like HIPAA.You've probably heard a few acronyms like EHR, EMR, and PHI get thrown around. All of these items have one common thread—their contents can be traced back to you, the individual patient, and because of that weakness, said contents are supposed to be protected. Your electronic medical record, or EMR, holds your medical and clinical history that are generally accessible by a specific facility's doctors and staff. This software is what doctors use in and out of the exam room to record medicines, changes to treatment, official assessments, etc. In the old days this info would be on paper in a thick manila or tan folder. Now it's on the cloud or saved to an encrypted hard drive somewhere. You may not be able to touch it, but caring for that data involves concrete ramifications. Obviously, your doctor needs your history documented cleanly and thoroughly to help you over time, which is why EMRs are the cornerstone of the medical field's day-to-day operations. One major issue happens when you need to go to another place that uses different EMR software—your individual notes don't just magically beam to your next destination like Scotty would do for you in Star Trek. This is why electronic health records, or EHRs, exist. EHRs are meant to be a combined record saved on a cloud server or sometimes a government database holding your accumulated info. An app like MyChart is a great example of this. Any medical info, whether it be stored by a healthcare entity on your behalf or if those records are in your own storage, fall under the umbrella of protected health information, or PHI. The core concept here, again, is that any of this data, which include date of birth, contact info, stated gender and medical records, can be traced back to individuals. This is where the Health Insurance Portability and Accountability Act, better known as HIPAA, comes into play. I swear that HIPAA is the last acronym I'll use today.The core purpose of HIPAA is to protect your personally identifiable data held by healthcare providers, health insurance plans, clearinghouses, and Medicare prescription sponsors. Those parties I just mentioned are what that law calls “covered entities.” Even though this act was signed into law in 1996, which believe it or not, is before twitter and smartphones, HIPAA's been revised numerous times because the world of technology moves so fast such that it becomes harder to protect health info. The HIPAA journal and HIPAA guide websites do a great job summing up changes to the law. I'll link those sources in my Substack post found at rushinagalla.substack.com. History lessons are cool but I want to cover the practical matters of record protection that patients should know. The stewards of your medical records can release said data to places like other healthcare facilities or to staff within a clinic who have to know certain things about you to give the best possible care. However, these parties still need to place reasonable safeguards for expected threats to your PHI—it doesn't matter if your info gets leaked by accident, that's still a serious issue. You can't stroll up and hijack a car like it's Grand Theft Auto, get caught, say you didn't know it was illegal, and then expect to go home free. The most common HIPAA violations to be aware of happen with facilities overestimating their security measures and from those places not training staff to handle sensitive material properly. Any clinic you go to or insurance plan you link up with needs to state their privacy practices. Unlike the terms and conditions or user agreement you might sign immediately with any piece of software, you should probably take a moment to listen when someone who keeps your health info tells you what they can and can't do..Some common themes come up for rights that should be made explicit to you. For example, you can request your medical record or ask for corrections to it anytime. You also have the opportunity to spell out who gets clear access to medical data and also how you'd prefer to communicate about health matters (i.e. over the phone, email, telemedicine, only face-to-face). This might seem trivial, especially because technology and social media dull our sense of what privacy means today, but telling the world on twitter what you ate for breakfast today is easier than telling the world you have diabetes.There will come a time when you need a copy of your medical or health record for something, whether it be for visiting another healthcare facility nearby or if you are moving somewhere far away. Although you have a right to request your record, each place handles information transfers differently. The best approach is to call your provider's office to get details on this process, but in some cases a hospital's website can outline what to expect. A facility shouldn't refuse to transfer your record even if you have unpaid bills with that place. HIPAA guidelines suggest that providers have 30 days to send your record in whatever format you request, which is sensible. I speak from my own experience helping patients do this because gathering and summarizing years of chart notes, labs, and commentary into one neat package is time consuming. At some point you will need to sign a release form showing at the bare minimum who you are, what medical info you want, and where the data are going. Certain patients might just wish for specific notes or lab results and nothing else transferred. In some cases, you might get billed for obtaining a paper copy, mailed copy, or USB drive for a medical record but this fee should be reasonable. If your doctor is just faxing your records to another physician, that should be complementary. In my view, picking up and hand-carrying your medical records is the best approach with minimal risk of loss via fax or snail mail.Now you get home and you have a moment to glance at the copy of your history. Even if your record has a lot of comments that are in medical-speak, there's no need to worry, because all your medications and provider's recommendations should be there in mostly plain English. Now that you know how medical info should be protected and how to get a hold of it, you can be more in tune with the overall trend of your health, especially because data expands so fast, all the time. Another thing growing a lot in healthcare are drug prices, which is the prime topic we'll break down the brief story of in our next podcast. Stayed tuned and subscribe to Friendly Neighborhood Patient for all that matters to your healthcare journey. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

A great doctor might be what brings you into a clinic but you won't stay there too long if that clinic and its staff treat you like crap. Once we're done with this episode, you'll be able to tell apart the good, bad, and straight-up dysfunctional clinics or hospitals.Obviously, the skill and location of whatever doctor you see matters the most in your choice for what clinic you join. Every great team needs its stars, but the reality is that in most places, the doctor is one major cog in a grand machine. The mid-level providers, nurses, assistants, staff, schedulers, etc. all should work in harmony. A badly managed practice brings down the best of physicians. On the other hand, a great practice with the most elite supporting cast on earth won't be able to redeem a god-awful medical diagnosis. You can think of this relationship like Tom Brady's and Bill Belichick's New England Patriots. Coach Belichick and his staff put all the pieces together for Brady and his teammates to consistently thread the needle down the field. That's why you should take note when a given clinic's staff and professionals communicate well. This is not going to be a discussion about what makes a great doctor—I'm going to need a couple of longer episodes to deal with that topic. However, the purpose of this episode is for you to know if a given medical office or team checks all the right boxes for being able to assist you properly.Part of the reason why patients can mistrust the medical community is because it's so easy for anyone to say their clinic is patient-focused, detail-oriented, and competent. If a healthcare facility's only selling point is being “patient-first” or “patient-centric,” you should question what that clinic has to offer. Hence, in no particular order, I'll cover all the major red and green flags to watch out for so you can see if a clinic can walk it like they talk it.You might hit the first possible roadblock before you even get out of the waiting room. Most clinics these days use an electronic medical record system to keep track of all their patients, and in some cases, you end up being just another number in their system. The staff or the doctor might be a little stiff at first because in the wider scheme of things, you could the 60th patient today who's coming in for aches or pains or covid. You might also be verbally labeled as just a “case” or “client” in an office's calendar. For some medical businesses, this is the reality but you should notice the clinics with staff who break the mold, call you by name and, for a moment at least, take interest in your day or story. You might also see the doctor having an attitude with patients different from the demeanor for his or her staff. Patients might get attention like they're Cinderella all dressed-up and the nurse or medical assistant might get a look as if they're Cinderella before she gets on that pumpkin carriage. You may not even see the same care team member twice over the course of a year. What could also happen is that you won't be able to get help because no one returns your calls or messages. If you end up in the unfortunate situation of having a treatment plan from your provider go wrong, the worst of the bunch won't bother to help you further because they want to be as far as possible from their most unsuccessful patient care outcomes. Factors like high turnover, low morale, people just going through the motions, and straight up disrespect at medical clinics can be a sign of toxic culture, but these are usually consequences of deeper issues. Since on this podcast we're all for being proactive instead of reactive, there's one cause of mismanaged practices to watch for. An ineffective practice at its core doesn't let patients tell their whole story. Staff may just cut patients off or express displeasure at the extra work of taking more history. Even worse, critical info about medical history you give to nurses, assistants, or schedulers doesn't make it to the doctor and other professionals. Your info needs to go all the way up the food chain—as mentioned earlier, strong communication between staff, doctors, and patients influences better results.Let me say one thing before we get up on the right side of the exam table. With respect to all the red flags we covered, it's still possible that you can end up at a practice where the doctor and staff are stone-faced and otherwise rude but still work together perfectly and get the job done with your health—such a context does exist, and if your well-being is better as a result, that's wonderful. That being said, negativity shouldn't be your main filter for seeing if clinics or hospitals run well. Let's go through all the important green flags.A good number of the right things a practice can do will be, of course, opposite from the red flags. For example, your history and important context get properly moved along to all the staff that need to know that info. Routine phone calls get returned in one to two business days. The office makes paperwork as well as pre-/post-visit documentation easy and mostly painless. The staff are genuinely curious about your story and let you do a lot of the talking. The clinic may be willing to accommodate you at the end of the day or early morning even when doing so may be inconvenient for the team. Physician extenders and nurses are empowered to help you but the doctor is still reasonably accessible. Staff learn from their mistakes fast and make things right with you in the case of an error. All of these habits I just rattled off make for a great start but the consistent and effective practices make sure their staff have clear roles. The first scheduler answers clarifying questions about the practice, books you for a time, and passes along your info to the other staff. The front desk and nurse or medical assistants round up the basic history while getting you ready for the main provider. The doctor or physician extender gives you a proper exam, answers more of your questions, recommends a clear plan, then passes you back to the rest of the staff to make sure that plan succeeds.In a nutshell, medical personnel should care more about your goals as a patient than the goals of the practice or pleasing the doctor. Regardless of all the good and bad incentives of how doctors get paid or how insurance plans work, satisfied patients are what make great clinics and hospitals last. As a result, the best of the best follow those habits. You don't need clinic staff and doctors to say they're patient-focused—if these people are willing to go above and beyond to build a relationship with patients at every level in the staff hierarchy, that's a great place to be.The care a medical facility gives you (or lack thereof) doesn't just apply to when you go to the clinic in person or via telemedicine. Your valuable electronic health info deserves proper treatment as well, which is part of why rules like HIPAA exist. Next week I'll spend time on how medical records should be treated by others and how to handle your healthcare data appropriately. Stay tuned and subscribe to Friendly Neighborhood Patient for healthcare insight. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Health savings and flexible spending accounts make for a nice crossover between money and medicine. This is not a personal finance podcast at all, but when I'm done with today's theme, you'll be able to take advantage of benefits good for your health and maybe even your pocketbook.The main concept here is that health savings accounts, or HSAs, and flexible spending accounts, or FSAs, have pre-tax money that you can spend on various healthcare items. I'm not here to give you tax or investment advice but I do want to point out a bunch of facts about these plans that are helpful. Most of time, you sign up for either plan via your work. The HSA is easier to understand so we'll start there—with this account, you or your employer make tax-deductible contributions which you can use for things like medical visit copays and prescriptions. A couple neat facts about HSAs are that your unspent money generally rolls over every year and that you can invest those funds like you would an IRA or 401(k). This all sounds wonderful but there are some limits, with the major constraint being that you can only qualify for an HSA if you have something called a high deductible health plan. I've talked about deductibles before in past episodes but the short story is that your insurance may require you to spend a certain amount out of pocket before coverage applies. The IRS defines these plans as having a deductible of $1400+ for individuals and $2800+ for families. This is why HSAs are helpful, because if you're spending money for medical help anyway, you get a little tax relief on top. The max amount you can contribute to an HSA in 2022 is $3650 as an individual or $7300 for a family. These numbers change every year based on inflation and the IRS's assessments. Whether you get an HSA through an employer or in some cases fund it yourself, the institution or bank who keeps that account will usually give you a debit card for your medical expenses. Even if you have or don't have an HSA card, you should keep receipts for anything you buy with that account, so you can easily lock in whatever reimbursement you need as long as the money goes toward something eligible.Thankfully you can find lists of eligible medical expenses from both the IRS and HSA bank websites—I'll link both of those resources on my post at rushinagalla.substack.com. It also doesn't hurt to check to the original HSA or FSA plan document you get at the beginning to see the specific expenses that are okay for reimbursement. Some employers have more or less restrictions on what you can use the money for beyond whatever the IRS outlines. You don't need a high deductible health plan to get an FSA. However, only an employer can give you an FSA. The confusing part happens when you realize there is more than one type of FSA. This is just classic healthcare making life complicated, but I'll break down the major kinds of FSAs. Although your average FSA can fund medical costs just like the HSA, some companies offer a limited-use version with money that can only be used for dental and vision care. You might also see a dependent care plan, or DCFSA, meant for child care, elder care, or some preschool services. It's actually possible to have both an HSA and FSA. In that situation, your FSA would be limited to vision and dental or dependent care facilities. Unlike the HSA though, you can't rollover all your unspent funds. The IRS has a 20% contribution rollover limit for FSAs every year but your employer makes the final decision on what is okay. Because of the pandemic and the recent American Rescue Plan, there are exceptions in place so you can ask your tax preparer about that if needed. For 2022, the contribution limit for a traditional medical FSA is $2850 for individuals. DCFSAs have a $5000 annual limit for individuals but are also subject to change. If you have the luxury of being able to choose between an HSA and FSA, you should think about your medical habits and tendencies so you can make the most of either plan.Regardless of the account you have, keep your receipts—if you ever need to send them to an administrator, your reimbursements will be easy to get. For example, you shouldn't hesitate to ask for an itemized statement from the medical office or pharmacy you go to often. Let's pump the brakes for a bit. The reason why I'm spending time walking you though all these items is that not everyone qualifying for these accounts takes advantage of or even knows about them! The Journal of the American Medical Association held a survey in 2016 and then reviewed their findings in 2020 for adults with high deductible health plans who have or can get an HSA. The AMA's study classified high deductible health plans with a benchmark of $1300+ for individuals and $2600+ for families (both upper limits are slightly below the IRS's definition). The sample of people who got interviewed were ages 18-64, all of whom had a high deductible plan for at least 12 months. The results found that just one in three people actually opened an HSA account and even fewer contributed to their respective accounts in the last year. All of this is the case while the share of privately insured adults with high deductible plans went from 25% in 2010 to 40% in 2016. In essence, patients have more out of pocket responsibilities but aren't taking advantage of HSA or FSA benefits that offset those issues. These trends are why I want to call attention to the fact that it's worth your time to check with your employer or tax guy if you qualify for those accounts. Just remember that if you actually get an HSA or FSA, save your account policy document and your receipts to make the reimbursement smooth.No matter how you choose to spend all that hard-earned pre-tax money, expenses should be taken care of at a clinic that treats you well. In the next post, you'll learn how to spot all the red and green flags of medical clinics. Subscribe and stay tuned to Friendly Neighborhood Patient for more healthcare commentary. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Telehealth and telemedicine offer so many benefits you should take advantage of. But just like how you might take whey protein, telemedicine should be a supplement and not a replacement for your health needs.The one thing we should clear up right off the bat is that telehealth and telemedicine are not exactly the same. Telehealth options tend to be more public-facing and include things like mental health or education tools. Telemedicine is more along the lines of getting official medical care through an app or software interface. Telemedicine can however, be considered a part of telehealth, just like how a square is a rectangle but not always the other way around. However, telemedicine and telehealth aren't replacements for in-person advice: like I alluded to earlier, you don't want your protein powder to replace your whole nutrition plan. For the purposes of this episode, I'm going to focus on telemedicine, the pros, the cons, and how you can use these tools correctly. You shouldn't use a power drill without knowing its limits.The fact that you can get medical help from your home or during your travels is pretty awesome regardless. Even though telemedicine was already growing before the covid pandemic began, the geographic barriers to getting care just went poof. Having this access is also great for the elderly, patients who can't move very well, and for busy professionals working from home. Now you might ask, oh Rushi this is nice and whatnot, but how do I actually get the virtual help? Whether you download apps like Teladoc or use a health system's proprietary software, there are usually three kinds of telemedicine visits. The easiest one to grasp is what some may call a synchronous or live consult. This is just what happens when you talk with a doctor in real time, probably over video. Any visit of this nature works best for when you can't make it to a clinic in-person but need an official medical opinion quickly. The next visit type is called asynchronous or store-and-forward. This involves you sending pictures or necessary medical history to someone who gets back to you with advice. In my line of work this is what happens when patients get worried about their moles and send pictures to get a handful of spots checked by the doctor. The last option is remote monitoring, which is when you have a provider check important stats like your blood pressure or glucose over time and make changes as needed.No matter what type of visit you prefer, the take-home message is that you should let telemedicine be your swiss army knife to get started on your medical needs in a timely manner. Some apps like Teladoc or MD Live can get you access to a professional in under 24 hours. Getting an opinion that fast is wonderful, but you should draw the line for what needs to be done in-person. However, this doesn't have to be black and white. Let's say you have a rash or some kind of break out. You open whatever telemedicine app is on your phone and you speak to a general doctor that same day. You might then get referred to a specialist like a dermatologist for in-person or virtual help to better fix your issue.Specialties like dermatology, radiology, family medicine, and cardiology mesh with telemedicine nicely compared to other sectors. We're not yet at the point where your surgeon could do many clean robot-assisted procedures from halfway across the world, but we're getting there. I'm going to link a longer article by the company eVisit that summarizes a lot of the telemedicine basics and screenshot a separate graphic that shows the best and worst uses of virtual care. I'd argue that telemedicine is at its peak when patients get continuity of care over a long period to ease lifestyle and chronic issues.Not everything goes to plan. I want to be fair in talking about the less effective side of virtual care. For one thing, not everyone is tech savvy, even in 2022. Both providers and patients might have problems with internet connectivity or may not know how to switch the camera on a phone. You don't need to a tech power user to fix this issue, but for virtual care you should use the device you find most intuitive whether it be your phone, computer, or tablet. Another issue is that we can lean hard on telemedicine or telehealth for replacing all in-person care, which can be dangerous because some issues might only be found during actual physical exams. Also, heaven forbid that someone would use a telemedicine app as a replacement for an emergency that should be taken care of with 911. As I've talked about in previous episodes, there are steps worth taking for exploring your options with in-person doctors. You can definitely try a combo where you see the primary doctor once a year and then seek assistance via telemedicine as needed throughout the year. Another thing to consider is that HIPAA and other privacy rules that govern how patients and doctors communicate online about health needs could also change on a dime. To address this concern, you can ask your provider or insurance company if the primary telemedicine platform being used encrypts your data and is HIPAA-secure. Due to the pandemic, there are exceptions in place but it never hurts to ask if the software of choice makes sense with a security standard. And last but not least, pricing can also be an issue. Since the onset of covid, generally speaking, insurance plans are willing to foot the bill for a remote visit, but platforms can still charge you a convenience fee per consult or providers might end up having you get services or advice that would be considered out-of-network. For those of us who ordered a lot of food from DoorDash or UberEats, the hidden and subtle fees on top of the main course add up fast. This why you should review pricing or fee schedules published on telemedicine platform websites or call the number on the back of your insurance card to get an idea of your virtual care benefits.Even with all of telemedicine's pros and cons, the long story short is to use the tools correctly without letting the tools use us. Although telemedicine costs and coverage might be murky at best, there are great tools you can use to handle your medical expenses, whether they be virtual or in person—the HSA and FSA! In the upcoming podcast, we'll talk about the heath and financial benefits of those accounts. Subscribe and stay tuned to Friendly Neighborhood Patient to get informed about healthcare. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Saying a doctor is busy is like calling the sky blue. You still might be asking though, why are clinic schedules so damn packed? After we take a trip behind the scenes for why the doctor's waiting room earns its title, you'll be prepared to handle any reasonable wait time.There are really two boxes to unpack for talking about how doctors get heavily booked: 1) the day-to-day operations (when the doctor is quick or slow to get you at any given time) and 2) the big picture trends and seasons explaining the congestion in the first place. This is why I'm going to split this episode into sections for those areas. We'll start with a situation that hits very close to home: you're in the waiting room, and you seem to be waiting much longer than you should. It doesn't matter whether you're going to a private clinic or the largest health system in your state. In either place, you're probably going to hunker down and scroll through your phone, twiddle your thumbs, or both while the doctor gets ready to pick you up.There could be many reasons why your provider runs behind or has a long wait-list, but one major factor that always stays the same is that doctors' earnings rely on volume and procedures—not by time spent per patient. Procedures involve both materials and motor skills as well as time it should be no surprise for that being expensive. But a doctor generally can't bill a consult to patients or insurance plans by the minute like a lawyer can, at least not without serious proof of medical necessity. This reality of the medical profession is a major part of why clinic schedules get overbooked and things run slow. Not to mention that demand for medical care runs high to begin with. A doctor's lateness on any given day usually varies by specialty. A mostly consultative practice like internal medicine or family medicine may not keep you waiting more than 20 minutes, but it could be normal for a popular surgeon to have an hour-long wait.Regardless of specialty, the fact of the matter is that day-to-day responsibilities unrelated to actual patient care pile up fast. Let's step in the primary doctor's shoes for a moment. You see your first patient at 8:00am for a 30-minute visit. You go through the usual routine of getting medical history, doing the physical exam, and hopefully putting together a treatment plan if needed. It feels like it's been five minutes but the clock has already moved 20 minutes. Then your patient has a last-minute concern or question right at the 29th minute. You're obligated to address those issues. You and a scribe are frantically trying to enter all this info on a chart note. Suddenly it's been 35 or 40 minutes and you realize there are 20 to 30 patients to go. Oh, and you also need to deal with any prescriptions, lab orders, follow-up plans and whatnot. In a nutshell, that is how a doctor's calendar snowballs. I'm not trying to put blame on either the doctor or the patient—that scenario I mentioned is just reality. Besides administrative needs there also could, of course, be an emergency, or there may be a doctor-to-doctor phone call that needs to be answered. Everything I mentioned tends to be the main obstacles to keeping an efficient schedule which these days seems impossible. This is why, even if you as a patient have an appointment that's supposed to start at 10AM, you should ask the front desk staff at the clinic what the current wait time is and if the doctor is running behind. A couple years ago when I saw my primary doctor, I needed to wait an hour in the exam room. When my doc finally got to me, he looked so rushed and harried that I didn't even bother to ask about the delay. This is why you shouldn't have any major plans booked right after a medical appointment.There's no doubt that medicine is a complicated profession and the issues we talked about throw the schedule out of whack. However, you need to have clear standards for what acceptable timing should be. My rule is that if a primary doctor or specialist makes me wait over half an hour for at least three appointments in a row, I'm getting my medical care elsewhere. You might be okay for waiting longer or less than I do, so consider what you can tolerate. I'll link some more background info for what slows down a doctor's schedule on my Substack page, which you can find at rushinagalla.substack.com. Sometimes though, you might be lucky enough to be part of a clinic that runs on time and keeps you waiting 10 minutes at the most. But the doctor's waitlist could be four months to book a visit. This is more of a big-picture, macro issue compared to the day-to-day factors we just went over.Of course, if a given doctor is skilled and popular, it would make sense for that person to have many eager patients lined up. That being said, medical offices do have a little seasonality. The clinic directory and promotion company ZocDoc crunched some of their visit data back in 2016 and put out some helpful insights with a graphic showing the busiest months of the year for each medical specialty. I'll link the data at rushinagalla.substack.com but generally speaking, the findings suggest that March, January, and August (in that order) tend to be the crowded months with November and December being less busy. This would vary by specialty. The main bias of this study is that most of the clients ZocDoc tracks are private or semi-corporate clinics that aren't necessarily part of a greater hospital system. Regardless of that issue, the general take-home point is that you should aim to book your visit in a calmer month and either early in the morning or right after a clinic's lunch hour. Another helpful recurring survey done by the healthcare staffing company AMN found that even back in 2017, the average wait for a new patient appointment booking was about 24 days! This is before the COVID-19 pandemic made schedules crazier. That number grew about 30% from 2014. The stats were drawn through five major specialties the study reviewed: cardiology, dermatology, orthopedic surgery, gynecology, and family medicine. That AMN study argues that increased health coverage, more chronic issues (e.g. diabetes, hypertension), and a continued under-supply of doctors are the main drivers for raising wait times. If you're having an emergency, you need to just roll with the given time that a facility offers, but the data imply that you should book medical visits more than a month ahead of time when possible. A simple calendar or app reminder goes a long way.With a little patience and the background info you know now, there are a couple takeaways from this topic. Getting medical care in a timely manner gets easier when you have 1) defined standards for delays you're willing to tolerate and 2) that you book your standard visits months ahead of time, especially when you can work to see your doctor for preventative rather than reactive care. One awesome tool that can also help you with navigating our medical system is actually telemedicine. Telehealth and telemedicine were growing before the pandemic but they're popular services now. We'll spend time in the next post on when it makes sense to use those virtual health tools. Stay tuned and subscribe to Friendly Neighborhood Patient for more healthcare guidance. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

You could say that medical advice and prescriptions are the salt and pepper of healthcare. Unfortunately, there will be times when you run out of prescriptions that you need to continue and you are worried about what needs to be done next. After this episode, you'll be able to handle prescription refills, no sweat.Let's say you're leaving the clinic with a treatment plan in mind and your doctor either gave you a physical prescription or sent an electronic one to your pharmacy. Now you fill the prescription either at the pharmacy or in the mail and you happily follow instructions for a while. Then you notice that you're out of pills or whatever cream you're using and you still have more treatment to follow through with. The first thing you should do here is to check if you have any refills. Usually on the paper or electronic prescription there should be a number that shows how many refills your doctor approved. Think of refills like this: your doctor whips up the play, meaning the treatment plan and drug, and then throws you the ball. As the receiver you'll get the ball but you still have to catch it. The major concept here is that refills don't just pop into existence, it's your responsibility to get them—not enough providers are clear about that. In this situation, you can just reach out to the pharmacy and get your medication refilled without needing to call the clinic (unless of course you have treatment questions).There are a few ways to get a refill, but in most cases you will need to give your prescription number. For example, on the pill bottle of a common medication like Metformin, there should be a label that will have your prescription number and approved refills along with other critical info like pharmacy contact details and your name. Since we live in the 21st century and have mini supercomputers in our pockets, using a pharmacy's mobile app or website is helpful to get automatic refills as long as you know your prescription number. Even with modern technology like this you can still have issues with a pharmacy's website and you may not be able to reach their team over the phone easily. Even when calling patients' pharmacies from my clinic I've been on hold for over half an hour sometimes. In the worst case scenario, where you're having problems getting a hold of the pharmacy, it's best to go in person if possible—just bring your ID and other basic info so the pharmacist or pharmacy tech staff can find your record. Having a mail-order for your prescriptions is a great set up also, especially if there are meds you need to take consistently over time.Even with all these great methods, you should know when to ask for a refill. Ideally you should contact your pharmacy if you think you'll run out of medication in a week or two and you know a refill is needed because you got a treatment plan to finish. I say this because even though pharmacies can be pretty fast with refilling common meds, you might still have trouble waiting for re-ordered stock especially with today's supply chain issues—it's better to have a little bit of lead time and be proactive.Numbers are an important theme here because most drugs are dispensed with a time limit or maximum quantity. For example, a tube of a common skin cream like Triamcinolone can be prescribed for 30 grams with two refills or the doctor can write up a 30-day supply with any refills allowed for that period. Although your provider is the one who decides the safe and effective amount of medication you need, it's actually the health insurance plans who lay down the hard quantity and refill limits to keep a lid on the US's already very high prescription drug costs. Health plans usually read over the latest clinical research and FDA guidance on each medication in the market to set those restrictions. The operations and content director at the GoodRx prescription indexing company goes into more detail about this in a separate article that I'll link on my Substack post found at rushinagalla.substack.com. When it comes to these limits though, not everything fits together well like that jigsaw puzzle you spent a few long days trying to finish. The best medicine varies so much by the individual that your run-of-the-mill prescription length or amount may not make sense. That is why both patients and doctors are welcome to ask insurance plans to approve unusual amounts of medicine with a quantity limit exception. Your doctor's office can file this and send any other pertinent clinical info the insurance needs to get this request done. One quick note before we get to the big picture. If a situation comes up where you lose a prescription or if you need a backup supply of meds for travel, you can reach out to your pharmacy to get an emergency refill (usually up to a 30-day supply depending on the medication). That being said, in some cases it might be easier to contact your doctor's office directly and get a new prescription.Speaking of new medications, you might be wondering what happens when you completely run out of refills. Thankfully, you're not the end of the road. You're now at the stage where you can ask for a prescription renewal. Just like how from very far away an emu looks like but isn't actually an ostrich, a renewal is not the same thing as a refill even if it's similar in principle. A renewal is a brand new round of medications and refills that get approved solely at your prescriber's discretion. You can ask for a renewal when you visit or call your doctor but you can also have the pharmacy send that request on your behalf. Sometimes your provider can have strict rules on how he or she manages renewals; either you might need to see your doctor for a visit every time you need a renewal or if you were seen in the last 12 months your provider may just approve re-upped meds immediately. Doctors usually want to interact directly with patients for prescription review just to make sure medical history, lab work, and your other health details are current.Now you're up to speed on how to get refills and renewals done on time and on target. What might not happen in a timely manner though is your return to the doctor's office and if the clinic even runs on schedule during any given day. In the next podcast, I'll break down everything behind the scenes that clogs up the doctor's calendar. Stay tuned and subscribe to Friendly Neighborhood Patient to get wise on healthcare. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

I can tell you for sure more people feel concerned rather than excited to visit the doctor. Some patients get anxious if not terrified of medical offices. All that being said, there are simple tips which can help you approach your doctor with confidence; no liquid courage required.Just like how we can be vulnerable during intimacy, discussing sensitive items with the doctor, to no one's surprise, makes for a lot of apprehension and worry. In the exam room, there are a zillion things you don't want to hear from the doctor that can stress you out. To name a few big ones, you might be worried about what you'll be diagnosed with, if you need to be pricked with a needle, or if you need to go through a challenging treatment plan. For many patients, hearing bad medical news or having an awful experience at the clinic tilts their opinion of healthcare professionals drastically. From my own experience seeing physicians and also helping patients at my clinic, I believe the worst thing patients can feel is the doctor criticizing them for having a bad medical situation in the first place. Although I'm glad this doesn't happen at my own workplace, other providers who victimize patients create unreal anxiety. Unfortunately, some doctors like that do exist. However, let me say one thing before you curl into a ball or stick your head in the sand: just like in entrepreneurship and other parts of life, it's a bigger risk to do nothing about discussing your health for the sake of dignity rather than be a little open about your well-being. As a little kid growing up with asthma, I used to keep my mouth shut when my doctor would ask me if I had that issue because I felt that if I didn't reveal my weakness or worries about my weakness, I could make myself feel better. As a result I didn't comply with the care I needed back then and things were much harder than necessary. I've learned it's actually better to manage your fears rather than manhandle them. That's why, right now, we'll cover straightforward tips on mitigating worries from seeing the doctor. I'll also link helpful resources from Mt. Sinai's and the Nemours' children's health systems that give a little more detail on ways for patients to deal with medical anxiety. You'll find these links, among others, on my post at rushinagalla.substack.com.If nothing else, you should know that you're not the only person on planet earth who fears the doctor. Just because you see other people on Instagram or Snapchat living their seemingly perfect lives doesn't mean they're unafraid of needles or tough medical news. Everyone deals with their own struggle behind the scenes. A clear sign of medical anxiety no matter what your background is happens when you're constantly rescheduling appointments better than procrastinating your regular work. Before even going to the clinic, acknowledging out loud that you are worried about the medical visit is the first step to self-compassion in having a better experience with a doctor. Voice to another family member or yourself that you're having this nervousness. Just like how you should have your visit goals in mind before reaching the clinic as we talked about in previous episodes, you can briefly rehearse the sensitive topics you're planning to cover. You could also hand your doctor some pre-written notes to go over so you don't need to bring up sensitive issues from scratch.Taking either of these steps keeps you from holding all the emotions and history so tight that you forget how to talk with another human being let alone your doctor. Here's another thing to consider from the professional's side of the exam table: good physicians are trained to discuss hard and uncomfortable matters besides solving health issues, while having more incentives to help you rather than judge you. If you close yourself up like a clam, the doctor would find it hard to get the additional bits of medical and social detail he or she needs to make the best treatment plan. Imagine your doctor totally missing something important like a smoking habit, rapid change in weight, or a new medication you take because you were too worried to say anything.Vocalizing your worries ahead of time lets you summon a little bravery in the exam room to open up the conversation more. The next couple tools we have to deal with medical anxiety, funny enough, come from how we navigate our children's healthcare experiences. Adolescents have their fair share of emotional and physical changes making them nervous at the clinic, but medical anxiety tips for teens and young ones can also make sense for adults. Along those lines, a nice way handle medical office fear is to bring a trusted friend or family member with you to the visit for moral support. It also doesn't hurt to ask the medical office ahead of time if you should expect any tests or procedures at the visit. If you know what's coming and have someone by your side, your medical care, among other parts of your life, changes for the better. All of that should be no surprise, but nervousness has a way of making us forget what we need to remember. Building trust with your doctors is critical for anyone but when you're young, that is a golden opportunity to be open with medical professionals, which then sets you up for better care in the future. The bottom line here is expressing that you want to take charge of your care while admitting your nervousness. That is music to the doctor's ears because the conversation then gets personalized for addressing your needs and worries. Even though it's better to do these things when you have your first medical visit experiences as a little human, it's never too late for owning up to your healthcare as a bigger human.Now you should be well-armed to handle anxieties at the clinic that are within your control. On another note, you might be walking out of the office feeling good about your treatment plan so far, but then you notice that your medications have a limited supply and the instructions are written in that classic doctor and pharmacy gibberish, pushing your stress levels back up again. For the next topic, we'll unpack how to deal with the confusing world of prescription refills. Stay tuned and subscribe to Friendly Neighborhood Patient for more American healthcare know-how. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Superman may be great at pretty much everything but the other heroes use their own particular skills for a reason. When it comes to medicine there are issues that even general practitioners can't handle, so when the time comes they will refer you to a specialist. Once we break down how referrals work you will improve your follow-up care with simple insights.When any given doctor sends you to another provider, the primary intent to get medical opinions, surgical work done, or diagnostic help to support the best possible treatment for you. Picture a scenario where you're in the exam room and your primary doc advises you to get a chest X-ray and visit a nearby plastic surgeon for something like a complex excision. This is where the hand-off in your care begins. A chord and line diagram made by the health tech company Amino shows the most common types of referrals. This retrospective study based on about 211 million referrals in 2016 shows that not every referral is a visit per se; a significant part of referrals from primary doctors like internists are directed to X-rays, EKGs, and mammograms. In essence, anything ordered for a diagnostic purpose is also considered a referral. When you open this graphic on my Substack post, which you'll find at rushinagalla.substack.com, you'll notice that internists, ER docs, and pediatricians are the common referring physicians, while radiologists, cardiologists, and dermatologists are part of the most popular rendering physicians. One thing patients get confused with is the slight difference between a consultation and a referral. The former concerns a doc-to-doc conversation for an opinion and the latter is a formal transition of care. For example, your internist might talk with a dermatologist about a rash you have to get insight on what treatment makes sense but you do not actually book with the dermatologist—that is a consultation. When you need to physically or virtually see the dermatologist yourself for the issue, that is a referral.There's one major concept I want to clear up for patients first: doctor referrals go beyond word-of-mouth because there are medical and legal elements that apply when getting in to see a specialist. A referral does not work like the sorting hat in Harry Potter that magically puts you where you need to be. As I've talked about in previous episodes, when you have an HMO or POS health plan you need to get a referral from your PCP to get coverage for a specialist. You don't need to worry about this if you have a PPO or EPO plan, but you and the referring doctor would need to check if a specialist would be in-network to begin with. Regardless of the health plan, the actual transfer of care is a standard or coded document originating from the PCP and insurance, or a letter from doctor to doctor with all your necessary medical history attached. With all the info and extra steps, both parties assisting in your care will be able to 1) prove that your referral exists so you don't get lost between offices and 2) legally bill your health plan. To be frank, referrals get so complicated that the average clinic has a separate manager or coordinator to handle them. Another factor to consider is that the wait time for a specialist like a cardiologist or dermatologist can take months. That's why if you're in a situation where you know that you need a particular specialist's expertise, it's a good idea to book earlier with your general physician to secure a referral in a timely manner. When the primary care office sends a referral, there's probably a limit on time or number of appointments you can have with a specialist. Insurance companies usually mandate such a duration so medical fees don't go overboard given that a specialist would charge way more than a general physician for a visit.Thankfully we can leave the insurance and legal side of things alone for the rest of this episode and dig more into how you and your primary doc can make a great referral just like a clean baton pass on a running track. If you've never had a referral before, it's best to trust your PCP's medical judgement when it comes to picking the specialist. However, you should get the contact info for a specialist's facility so you can research how their office works. Basically, trust the medical opinion from your doc, but verify that the office you're being sent to is accessible. The two big red flags to watch for are if the PCP does not follow up with you to see if your referral went through and if the specialist's office does not contact you within two or three days of getting the referral. To nip any problems in the bud, I suggest asking your PCP exactly what to expect for the referral in terms of urgency, visit expectations, and the content of what he or she is sending to the specialist. The American Academy of Family Physicians has an old but surprisingly applicable template of how the elements I mentioned fit together. The article will be in the post on my Substack page again found at rushinagalla.substack.com. Some physicians are going to be very hands-on. The proactive general doctor will call the specialist's or lab's office to speak with the rendering physician and provide other information about you that may be hard to define in an electronic medical record. Think of this like how a pro football scouting report gives you nitty gritty details on the opposing quarterback but a human coach walking through game film of the quarterback in action gives you even more insight. If your doctor cares and advocates for you this much, hold them a little tighter than a winning lottery ticket. The opposite end of the spectrum is the doctor delegating the majority of referral responsibility to you. Here your PCP sends a referral letter to another office but may give you prescriptions, labs, or any necessary written chart notes to hand off to the specialist when you go in.The content of a specialist visit will be more focused than a traditional checkup. There are specialists who do take a holistic approach to their care but in most cases, they will address only your immediate medical priorities and PCP's main concerns. Regardless of format, make the most of the time you have, continue to ask important questions like with a routine checkup, and get the written visit summary, assessment, or treatment plan after everything is done. You can also check if the specialist will send notes and correspondence back to your PCP. Your general doctor should also make clear with the specialist whether you are going to be immediately released back under the primary care office's wing or if you need to continue following up with the specialist. Naturally this is going to vary with your current medical situation. In any case, we've finally closed the loop for how a typical referral works! The bottom line is that a ensuring a successful hand-off of medical care happens when you get transparency and clear expectations. When the time comes for you to get referred to specialists or labs, ask your PCP what their office's exact referral process is, and get the contact info for where you are being sent to.Before we finish up, there's one question that might have popped up in your mind: what if I'm a little nervous or too scared to ask my specialist any questions or advocate for myself? This “whitecoat syndrome” is actually a real thing and there are plenty of patients out there who fear going to a clinic, but coming up next, we'll talk about ways to deal with that anxiety and have an easier time face-to-face your doctors no matter where you go. Stay tuned and subscribe to Friendly Neighborhood Patient for even more medical system tips and tricks. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Whether individuals or employers pick your health coverage, you can still make sense of insurance choices to match up with your lifestyle and current medical situation. Knowing the relationships between various insurance components makes each plan type digestible.Before we even talk about insurance plan types, we need proper self-awareness. If we know ourselves and our health tendencies, we'll find a better insurance plan fit. This logic applies both to individual patients picking health plans from online marketplaces and businesses purchasing health plans for their employees' best possible coverage.The major tradeoffs for any health plan involve the relationships between deductibles, out-of-pocket limits, provider access, and premiums. In general, the monthly premium you pay for the privilege of coverage falls if you have a high deductible and/or a small provider network. On the flipside, paying a ginormous premium should give you both comprehensive and vast coverage. Rather than trying to get lost in the sauce with all those complex numbers, it's better to ask yourself some targeted questions first to find proper balance of payments with your need for care.I'm going to link on my Substack a great article from NerdWallet with a full list of insurance considerations and plan comparisons, but for now we'll cover the two best questions with the most impact on your choice. Ask yourself: do you see your primary doctor or a specialist a lot? If you do, you should keep in mind whether or not your preferred doctors take your insurance and also if you need to drop significant copays and coinsurance when going to the clinic. The next thing to ask is this: are your current medications covered under insurance and are they brand-name drugs? Insurance companies talk about what drugs they do and don't cover on a huge list called a formulary. You can request the current year's formulary from the insurance directly or check it out at the company's matching website so you can know for sure if your current meds are approved or have alternatives.Once you finish that Q&A with yourself, the next step is knowing the actual plan options. The four most common plans are the PPO, HMO, EPO, and POS. The differences between the plans vary by how wide your provider network is and how your care is coordinated to begin with. Let's dive right in: the PPO, or preferred provider organization, is where the insurance gives you approved coverage for a specific list of providers and facilities. The people on that list would be considered “in-network” where you can get healthcare at the lowest negotiated cost possible. Think of the PPO like how Apple designs its product in-house with all the features but the action of making that product real happens elsewhere. This insurance dictates your coverage but is otherwise hands-off during the moments when you actually get your healthcare. You're still welcome see a provider who's not on the PPO's list but you would definitely have a higher cost of doing so, usually with increased deductibles and coinsurance.The HMO, or health maintenance organization, on the other hand is pretty much what happens if an insurer runs the whole supply chain of both medical care and the financial components of coverage. Kaiser Permanente is the example of an HMO and is the largest one in the US. If you happen to be a Kaiser member, you get access to their doctors, their facilities, and insurance administrators for supposedly a better price. The only major disadvantage is that you cannot see anyone outside of Kaiser or another HMO unless you enjoy footing the entire medical bill. You would also need an official referral to see any specialist, like a surgeon or dermatologist, which can slow down your care in some circumstances. In this system you need to have a primary doctor who coordinates all your orders and referrals.Another insurance type called the EPO, or exclusive provider organization works just like a PPO but you can't see anyone out-of-network without paying full price. With this plan your provider network is restricted like HMO, but you can see a specialist without a referral or extensive oversight from a primary doctor. If we stick with our previous example using Apple as the PPO, we know that the company designs the iPhone in California, makes the phone in China, and you can use it anywhere once you buy it. If Apple were an EPO plan, imagine being able to use the iPhone only in your state or town and nowhere else. The final major plan, called Point-of-Service or POS, is (to keep things brief) a hybrid of an HMO and PPO. My Substack page for this episode found at rushinagalla.substack.com will have a table showing the major pros and cons between all the plan types I mentioned.For now though, let's just pump the brakes: how can you make apples-to-apples comparisons, even if there are more insurance plan variations than there are shades of gray? Believe it or not, it's possible to line up insurance plan options just like your Amazon shopping cart. The holy grail document you need to pull this off is the summary of benefits and coverage (SBC). The point of the SBC is to show out-of-pocket costs, common medical event scenarios, and covered or excluded services in one place for any given plan. I'll link an example of this on my Substack home page as well.SBC documents can be found on any insurance marketplace website or healthcare.gov. If your employer is giving or sponsoring the insurance, then reaching out to your HR department is the best move to get the summary. When you get a chance to lay out each plan's SBC side by side, you can see at a bird's-eye view what you need to pay for various items like getting traditional visits, lab draws, complex but routine surgeries, certain therapies, and more. It also doesn't hurt to ask the insurance company directly for policy documents if you need to check the fine-print coverage for a specific procedure, drug, or lab draw which the SBC may not have room to comment on.Since we've gone over the most critical items for plan considerations, plan types, and comparing those choices with an SBC, we can keep taking steps for learning how other parts of medical care fit your lifestyle and situation. As we've discussed before, your insurance plays a huge role in how much power the primary doctor has over your care. However, there will come times when you need to see a specialist with expertise that an internal medicine or family medicine doctor can't offer. In the next post, I'll unpack the black box that is getting a specialist referral so that aspect of care will be less daunting, more productive, and empowering for you.Subscribe and stay tuned to Friendly Neighborhood Patient for more practical healthcare guidance. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

It's hard to pick the flavor of ice cream you want at the shop unless you know yourself well. I know I'm that guy who takes forever to pick something when I'm in line. Choosing to get your healthcare in a private or public setting can make you feel the same way. Once we go over the major types of medical practices, you can rest easy with finding an office that's a great fit for your needs.You should have a say on what kind of medical practice works best for your situation, but there are tradeoffs as the practice size increases and decreases. Before we dive into the various types of medical practices, it's critical to know the incentives on the other side of the exam table, meaning, what do doctors have to consider when it comes to owning their practice or being employed by a hospital/corporation? In a totally private setting where the doctors own everything, they can practice exactly how they want. These physician-owners shoulder more administrative burden. Employed physicians, especially in a hospital or corporate environment, get security from a paycheck and in theory can just focus on patient care but with some more red tape involved.According to the American Medical Association's most recent biennial survey of physicians in Fall 2020, 49% of active physicians work in a fully private setting with complete physician ownership—that is a five-percentage-point drop from 2018. The next 40% of doctors worked directly for a hospital or health system, including smaller practices that are owned in part by a corporation. Consolidation is the best word to sum up medical practice trends over this past decade. Now let's step away from the doctor's side of things to understand what the medical practice pros and cons are for you, the patient.Think of practice settings like the differences between traditional ice cream, gelato, or a sorbet. All those foods have the same purpose of appeasing your sweet tooth but in distinct ways. Along the same lines, all medical practices are supposed to heal and enhance you but the setup changes how that process works. The simplest office to grasp is the solo practice. This the clinic that your grandparents would describe like, “back in my day the doctor was also the bookkeeper and the receptionist.” In this situation, the doctor has no other partners or employed professionals other than basic staff. You as a patient mainly benefit from the doctor having skin in the game. The solo doctor takes a huge financial and personal risk to keep the clinic this way, especially with rising medical school loan payments overhead. Therefore, if the solo provider messes up badly, the patient population disappears in no time flat. As a result, you get more attention and niche expertise. Seeking this kind of practice makes sense if the doctor you're looking for is a specialist for a particular condition you have. Like if you have a propensity for skin cancer, seeing a dermatologist who mainly takes patients for those cancers in a solo or small office could make sense. The solo practice is a dying breed though—currently 14% of physicians (and decreasing) still run things like that.If we move up to the heaviest weight class, we find ourselves with hospitals and corporate medicine, both of which are growing. Think of the VA, Stanford's health system, or The Cleveland Clinic as examples. Pretty much every professional at those places is employed and not, at the end of the day, beholden to patients even if that is what they are paid for. It really is the opposite of the solo practice we started with. Devorah Goldman's December 20th editorial in the Wall Street Journal illustrates the major con of big medical settings turning into assembly lines of care. But with all that being said, people still go to hospitals and corporate health systems to get not just emergency care but also supreme access to resources, technology, and expertise that a small clinic may never offer. Red tape and zero physician autonomy are just the main drawbacks here.With the final common medical practice styles, we can meet in the middle. Simple examples could be like a primary care clinic that has 10 internists or a cosmetic outfit that has two dermatologists and three plastic surgeons. The former example would be considered a single-specialty and the latter a multi-specialty practice. In this scenario physicians can be employees or partners in the clinic—in fact, ~69% physicians run clinics with these setups. From the doctor's side of things, these group practices spread the financial risk among partners and usually have more administrative firepower to handle a lot of patients in little time. People can argue that group practices are the Goldilocks's of all the clinics, because as a patient you get the best possible balance of access to better medical equipment and facilities along with the facility itself not being so large that the care gets bureaucratic and the doctors forget to respect your story.Now that we've covered the basic kinds of healthcare settings, what should all that mean to you? Coming back to ice cream is the easiest way to explain things. You may love gelato more than regular ice cream or sorbet, but nothing is stopping you from getting the benefits of all three depending on your current taste, or in the case of healthcare, your specific medical needs. Obviously, your health insurance plays a huge role in places you can or can't access but you should be taking advantage of all the practice types that apply to you. If you happen to consider yourself a reasonably healthy individual with a small handful of routine medical issues to address, you probably benefit the most from visiting small offices or single-specialty groups matching with your needs. If on the other hand you have a variety of severe and chronic issues to work through, most of your care may happen at a hospital or massive health system with the most resources for treatment options. Overall, you're now in a better position to judge the appropriate practice setting—just remember that you get both more resources and more bureaucracy as the medical setup gets larger.Since we've gone over the major types of medical practices, we can thread the needle back to health insurance. One major decision you make (or more likely your employer makes) is to pick an HMO or PPO insurance model for coverage. Even if you don't know what those acronyms mean yet, knowing the important differences will help you choose the coverage making the most sense alongside the type of medical practice you want to visit.Stay tuned and subscribe to Friendly Neighborhood Patient for more savvy healthcare guidance. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

You might think your insurance will be a gentleman and pay for dinner, but the company will probably split the bill or make you pay the whole thing instead. After this episode though, you'll be able to tackle the basics of health insurance like deductibles and copays without a problem.Understanding your medical insurance might feel like scaling a sheer cliff. Once we cover the basic concepts you'll have enough hand- and foot-holds to do that climb. Before we start that let's check out the big picture. The concept of insurance should matter to you because in 2020, just over 91% of all Americans had medical coverage during all or part of that year. Employers are still the biggest customers for insurance, covering around 55% of the population. Medicare, which is handled by the government, covers the next 18% of Americans. These stats all come from the most recent US census. This all means that medical coverage will touch you or be offered to you in some way. That or you'll have a sleek-looking insurance card that doesn't actually cover anything. Regardless of whether it's publicly or privately funded, health insurance still has a few core mechanics, all of which are based on the idea of “medical necessity,” which is a broad phrase by design so the insurance can justify paying or, in most cases, not paying for your care. Once we know the lingo, it's easier to grasp different styles of plans.I linked a couple glossaries of health plan terms from the Bureau of Labor Statistics and UPenn's student health service on my Substack home page, which you can find at rushinagalla.substack.com.Now we can go ahead and master three major pillars of coverage: copays, coinsurance, and deductibles. Copays are easier on the uptake—they're just a fixed payment you make on the same day you are seen by the provider or medical facility you go to. For example, your insurance says that you have to spend $50 for a copay when seeing your primary doc. However, the first curveball here is that your copay can vary across different services. That $50 copay for your primary doctor can turn into a $100 copay at a specialist. In any case, you can just think of copays in terms of dollars.The next concept to attack, coinsurance, turns up the heat a little bit, but I'm confident you can handle it. Think of coinsurance as a percentage that you want to keep as low as possible. For a regular visit your insurance might say that you need to pay 30% of the bill before the rest is covered. That percentage would definitely vary between seeing a preferred provider or someone who's out of network (i.e. a provider who does not accept or have a deal with your insurance company). Your insurance can still make you responsible for more costs even after you pay coinsurance if the provider bills for something that the health plan won't cover no matter what (like a cosmetic enhancement or removal).Let's move on to the infamous phenomenon that is the deductible. Think of it like a comically expensive toll gate. A deductible is a minimum figure you need to spend on your healthcare before insurance covers anything. My insurance for example demands that I spend $1000 out of pocket during the year on regular visits and services. Depending on the health plan you can have multiple deductibles for individuals, families, different services, and out-of-network care. Even though I haven't met a single person who enjoys them, deductibles are common in health plans with low premiums. The premium is just the monthly fee you or your employer pays to have medical coverage in the first place. There is some good news in all this: a decent number of health plans can still fully cover preventative care visits, like seeing your primary doctor, without forcing you to pay a deductible. It's like having the privilege of free drinks and a table at the clubhouse where you pay thousands a year for membership. I'm going to link a useful article from Verywell health on my Substack, again found at rushinagalla.substack.com, that covers those nuances further.Believe it or not, there is a light at the end of the tunnel where your insurance covers just about everything. That light is the out-of-pocket maximum. This is best served with an example. If your health plan has a coinsurance of 20% and you get an eye-watering $100,000 hospital bill, you would think that you need to pay $20K (=0.2 * 100,000) before any coverage happens. But if you happen to have an out-of-pocket max of $10K for the particular hospital work you got, then your insurance picks up the other $90K if you have met all other copay/coinsurance/deductible obligations. This sounds all well and good but you probably have an out-of-pocket maximum just for in-network providers and emergency services. If you know you're getting something complicated in the near future like a knee replacement or extended drug therapy, it's smart to call the number on the back of your insurance card to ask for what your out-of-pocket max would be for a given medical situation. Most insurers will also slap on a lifetime limit. This reflects the fact that your insurance will only pay a certain amount for you, usually in the single-digit millions, over the existence of your membership. So if you wake up one day and want to replace your body parts with some flashy cybernetics for a few million bucks, just keep in mind what your lifetime coverage is and whether or not particular services are included with coverage.But to get back on track, let's just do a quick recap before we close things out. Long story short: think of copays with dollars, coinsurance with percentages, and deductibles with toll gates. The plot twist here is that your insurance may combine two or three of those payment types. So just be aware that, for example, you could have a $2000 deductible then 10% coinsurance for everything after that.For now though, we'll take a break from insurance side of things and shift back to medical care. Knowing when to seek private healthcare or hospital and corporate healthcare is the next thing we'll talk about so you can take advantage of the coverage you do have! Subscribe to Friendly Neighborhood Patient for more healthcare tips and tricks. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Here you are opening mail to find that your insurance sent a letter which is apparently not a bill, yet it says you owe money for your recent doctor's visit. Once we translate this letter into English, you'll have nothing to worry about.This letter I'm talking about usually arrives in the coming weeks after any given medical visit or service. This document states, in bold lettering, that it's not a bill, yet the number of dollar figures on there raises your blood pressure anyway. This letter is an explanation of benefits (EOB). It's supposed to show how your insurance is covering or not covering medical care. If there are times in life where you need to keep your expectations low, reading your EOB is one of those times. Before we dive in, there are two main reasons why you should take a glance at your EOB: 1) to check if you will owe any medical bills later and 2) to make sure your provider billed you correctly. Soon you'll be able to take care of these two goals no problem. This is how we'll dip our toes in the muddy water that is American health insurance so we can get more comfortable with time.Even though there are probably more EOB formats than flavors of vanilla ice cream, the core pieces stay the same. Usually, there is a table with various numbers. The top left or top right of that same page would have the patient and insured person's name, claim and policy numbers, and the medical provider's info. The real star of the show is the table, so for now we will focus on how to read that in particular. I will have an example diagram in this post and on my newsletter's home page at rushinagalla.substack.com if you want to follow along. Even if there are more than ten columns on an EOB table, three major categories should stand out to you. 1) The medical care, 2) the charges/what you are billed, and 3) the money you actually owe after insurance coverage (or lack thereof).In terms of the medical care, you should be seeing a brief one-line description for the actual service you got done in one of the left-most columns whether that be something like an office visit, lab draw, or a surgical procedure. That written description gets paired with a five-digit number called a CPT code, which I will talk about later, but you should make sure a date is there along with that code. That “date of service” should match with your own record of when you were at the clinic.Now for the charges. The largest dollar number on that table is likely the full amount billed or claimed by your provider. This is where your insurance company begins to cut that number down with things like allowables and discounts. Most providers negotiate with your insurance to get pre-approved rates for every visit and procedure. Let's say your doctor bills you $100 for a typical office visit. Your insurance might say the doctor can only bill $90 for the appointment and on top of that, the insurance applies another $30 discount because you saw that doctor within the health plan's preferred list of physicians. Suddenly the balance so far is $60 (= $100-($100-$90)-$30 insurance discount), which is the final amount the provider should be paid. Now we're at the moment of truth to see if your insurance feels like paying that leftover $60. If you're lucky enough to have bulletproof coverage, then your insurance pays that $60 to the clinic and you can now enjoy the rest of the day with whatever you do after five o'clock. However, that $60 is also the point where your deductible, copay, and coinsurance may apply. I will spend much more time on those concepts in the next episode, but for the purposes of this example, let's just keep things simple.Say your copay is $40 and you spent that amount already when you went to the clinic. A copay is just a fixed payment you give to the office on the same day you get seen. Now your EOB's final column might state that you now owe $0 from that $60 balance which means, after your copay, the insurance covered the other $20 (= $60 balance -$40 copay).Whenever you owe any more money to the doctor's office, your EOB will highlight that amount as “patient responsibility” which is a fancy way of saying that you should be happy when paying up. I have yet to meet someone who enjoys paying their doctor more than necessary. Overall, I would suggest that you keep all your EOBs saved in one place so you can easily check how effective (or not) your coverage is over time.A couple quick side notes before we move on: the EOB will have a little footnote or other number in the table called a remark code, which you should make sure to check, because those comments might explain why parts of your visit charges were adjusted or denied. Also: every time you get official, on-the-record healthcare visit or service, you should get an EOB even if you do not have a bill to pay. If you don't receive an EOB statement that you're expecting, go ahead and contact your insurance company or medical office ASAP (some health plans may just give you a copay receipt instead of an EOB). If one of your parents or your spouse is the primary insurance holder, that person should receive the EOB first.I realize that I've thrown a lot of stuff at you so far but now we can talk about the big picture on how to check if your medical charges and coverage are kosher. The first two things you should check for accuracy on your EOB besides your basic info are the date of service and the procedure code for that service. That five-digit procedure or visit code is shorthand for any kind of medical care you receive. Most providers use the CPT code system when sending a claim. You don't need to be a coding expert to know if your EOB is proper. Just take the CPT number on your EOB (e.g. 99213, 11102) and Google “that number + AAPC.” That acronym (AAPC) is for the American Academy of Professional Coders which is by far the best resource for defining any of the services you get. That page is another link I'll have on my Substack. If that code you looked up from your EOB does not match with the actual experience of what you had at the clinic, like if you went for a visit but the letter shows you had a surgical procedure instead, something is definitely wrong. At this point you should call the doctor's office to check why they coded the visit incorrectly and if they possibly overcharged you.With all that done we've accomplished the two basic goals for how to read your EOB and get your beak wet for understanding the link between your medical care and insurance. Now you can see how much you owe for medical care and get an idea of the clinic billing you appropriately for corresponding services. Even though I've seen and written my own fair share of medical claims, my head still explodes when I talk about insurance too much, so we'll save our discussion about major concepts like deductibles, coinsurance, and copays for the next podcast.Stay tuned and subscribe to Friendly Neighborhood Patient for more healthcare tips and tricks. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

You're at the doctor's office, the visit is just about over, and you completely forgot why you're there in the first place. Trust me, I've been there before too. But fear not! Getting ready for a routine visit is as easy as walking the dog or minting an NFT.You can prepare yourself well for a regular physical before you even set foot in the exam room. Besides reviewing everything I've noticed from my own experience running a clinic, I checked out a few sources including the government's Agency for Healthcare Research and Quality (AHRQ), the New York Times, and comments from Aetna's chief medical officer talking about how to get ready for a routine visit.Let's start with the thing you should get done even if you forget everything else I'm going to say. It's astonishingly simple: just write down two or three items or major questions you want to cover at the visit. This checklist of your mission-critical concerns focuses your visit and helps the doctor guide you through what you need to know. One example of a list would be: 1) discuss how to keep my blood pressure down, 2) what lab tests are best to run at this point in my life, and 3) can you or a specialist help me with condition X? This is not homework for you to turn in—this prep is just for yourself and for communicating with the clinic staff at the appropriate time. Making the checklist is easier when you nail down what your aims for the visit really are. Are you just wanting to check the boxes for making sure you are doing well? Are you having a new health issue that you need treatment for? Or do you want to focus on preventative care due to upcoming life transitions? These are the broad categories I've found useful for thinking of visit goals.Now let's approach your prep from the other side of the exam room: what do physicians wish for patients to bring to the clinic? If you are joining a clinic as a new patient, bringing your complete medication, vitamin, and supplement list is a must that is easily overlooked. You should leave no stone unturned for spelling out what you put in your body. Your doctor will also appreciate you explaining a rough timeline of your symptoms whenever a new health issue comes up. Of course, if you know what your symptoms are suggesting and you already have a treatment in mind, then you would not be going to the clinic in the first place. That being said, you can still be in tune with your well-being to make the doctor's job easier which makes the visit better.If you've been seen by another provider already, you should bring records of previous visits, especially when you switch between health systems and clinics using medical record data that cannot talk to each other. Once you have your shortlist of visit goals and basic history in order, more than half the battle of having a great visit is done.Before we keep going though, let's back up for a second. The reason why I am talking about all this preparation is because the length your actual visit itself is painfully short. According a retroactive study by the American Public Health Association's Journal of Medical Care, the average length of a primary care visit was 18 minutes. This conclusion was drawn from data covering over 21 million primary care appointments. The study's authors, who originally got the data from the IT company Athenahealth, also noted the average excess visit run time as 1.2 minutes. Put yourself in your provider's shoes for a moment. Imagine trying to get someone's history, perform an exam, suggest treatment, and answer questions in 18 minutes. And the doctor has to document all that in a chart note, then see another 50 patients after you. This is why you need to take advantage of every second in the clinic. You may not even be meeting with the doctor the entire time during the exam room, which is why you should communicate your visit goals and major questions to the medical assistant or nurse bringing you to the exam room and taking the initial history.Asking why primary care visits are this compressed is not too different from asking why we use quarters and halves for sports games. There are a variety of reasons, some of which are arbitrary, for why medical visits are like this, but that is missing the point for now when we have the ability to make the most of the time we do have.Now we can talk more about things to consider during the performance of your visit. You'll want to balance going with the flow of the exam while also circling back to your primary concerns when needed. Depending on how the exam is going so far, you should not hesitate to put in a clarifying question or two like “how is X procedure done, can you define XYZ condition, or what should my expectations be for results.” Just avoid breaking your provider's rhythm by asking something every two seconds.If you are legitimately worried about some particular health condition, it does not hurt to ask point-blank how concerned you should be. Then you can gauge your provider's reaction, assurances, and comments on treatment. When you get to the point where the doctor seems to be giving you clean bill of health so far, it would also be in your best interest to get feedback on what preventative care to get depending on where you are in life right now. This could take form in asking something like: do I need to get any screening tests within in the next few years?Every question and prompt we have talked about so far got us through the meat and potatoes of the visit. With that done we can move to the appointment's endgame or two-minute drill. You should not leave the clinic without getting a visit summary from your PCP. Usually, a visit summary would include your documented meds/symptoms, the doctor's comments, and most importantly the assessment and plan for what you need to do next. The office can print this for you or have the summary forwarded to your electronic medical record. This is also a great time to check if your doc wants you back at the clinic in a year or another time. Since your health priorities will be fresh in your mind right after the appointment, or at least until you start looking at your emails and social media again, you should put any necessary calendar events on your phone to confirm any future appointments, prescription pick-up, and lab orders. If for whatever reason the visit is winding down and you have not had your main visit goals addressed, it is worth politely redirecting the conversation with your PCP to talk about those aims.All that appointment prep we spent this episode talking about so far sets you up for healthcare success, but now let's recap the two essential things to do even if you forgot everything else. Writing a couple visit goals before the visit and making sure to get a written summary after the visit greatly enhances the value of even a routine physical.“We have the ability to make the most of the time we do have.”You will realize that in the coming weeks after the visit you will probably get a strange letter from your insurance that claims not to be a bill but has a lot of distressing dollar signs and funny terms on it. In the next episode we'll talk about how to translate those explanations and other medical codes into plain English. Subscribe to Friendly Neighborhood Patient for more healthcare tips and tricks. I'll catch you at the next episode. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

What is a primary care provider, why do I need one, and how the hell do I find one?Contacting a primary care provider (PCP) or a primary medical doctor (PMD) is a great first move when you need a new health issue addressed or if you want preventative care and guidance. These are the professionals you want to have a great relationship with. You should not settle for seeing an absolute jerk of a doctor, regardless of how great he or she may be. Getting effective medical care from a professional should not be like a fast-food drive thru or vending machine. You cannot hit a button related to your problem and expect a bag of magic pills, at least most of the time. So why should you invest in your relationship with a PCP? The answer would be continuity! Just like how your social media apps get better at reading your mind based on your activity, your medical care tends to improve when a professional follows you for enough time.So what kinds of primary care providers are out there? Internists usually see patients above 18 y/o and pediatricians below 18 y/o. Family medicine docs see patients of all ages and are the true jack-of-all-trades in the medical field. Ladies can designate a gynecologist as a PCP, but in some cases insurance plans may place restrictions on doing that. Check if your health plan makes you pick an internist or other traditional PCP instead. Older patients with chronic and/or several complex issues may also consider a geriatrician as a PMD.Even though you will hear me say that you need a doc for this and a doc for that, the patients considering themselves to be perfectly healthy may find a better match with a different healthcare professional like an FNP instead where the patient can have various primary needs addressed but can still get referred to a specialist when needed. It is more important to strike a balance: make sure to have a medical provider who has both expertise and professional courtesy.According the Kaiser Family Foundation, there are around 495k active PMDs in the US as of September 2021. In our country of over 330 million people, it should be no surprise that low supply makes it hard to get scheduled with any doctor, let alone a good one. About 25% of those PMDs are in CA, NY, and TX alone.So how can you find a reasonable PMD? Most websites and forums will tell you to seek out friends/family or use your insurance plan's directory. While these sources are nice, not everyone is fortunate to have family in good medical hands already and health plan directories themselves may not be up to date (plug BCBS, UHC, Healthline source here).Let me make this easy: crack open google maps and type ‘internist/pediatrician near me' or write ‘internist/pediatrician in [insert your town here].' Convenience to medical care should matter just as much as how solid a professional's advice may be. Even when your insurance company requires you to designate a PCP, you can seek out whatever prospects are reachable. Go check out the map listings, scroll past the ads, and certainly read some reviews. But don't stop there! If you want another sophisticated tool to complement your impeccable google search, see Medicare's physician comparison site, which is also linked on my Substack's resource page (at rushinagalla.substack.com).Now for the good part: it is better to hear things from the horse's mouth and actually contact the prospective medical offices you see on your computer screen. Good offices want to have nice conversations with new patients and are usually willing to go over all the nuances with you. There is no reason to be shy. Let me give you a few basic questions to ask for improving your screening process.Here's the first thing to open up with: do you take new patients? If you get a ‘yes' then you should follow up with asking what to expect with the first consultation. Given that you are new, there is more history for the PCP to collect. Some physicians give new patients more time for the opening visit or change the overall structure of the appointment. The office's response to describing how new patients are treated should matter in your screening process.The next thing to cover is this: does your physician have experience treating the condition I have? Your expectations here would vary based on your social, personal, and family history, but understanding if a prospective doc has been treating patients with certain conditions for X number of years is a great thing to know regardless. We know already that PCPs treat you for a wide variety of conditions—that being said, we all know what an iPhone does but we still check what the features and specialties are for each new generation. This is why it is helpful to know what kind of tilt a prospective doctor has.Now it would be reasonable to ask another necessary question now rather than later: does your doctor and facility take my insurance? Although you should expect a yes or no answer to this, you should remember that there are a gazillion variations of plans under each insurance network. This is why it is best to have your insurance card handy when you ask that question to clarify what specific health plan you have. You are now making the office staff's job and your screening process easier.The last effective question to ask, which tends to be overlooked, is: Can I get labs and tests performed at the clinic itself? When your new PCP gives you some orders to fill you do not want to realize right then that you need to go to another facility to get additional medical care taken care of. Some primary care facilities are fully equipped to have a test drawn on site but it is easy to know for sure when you ask about their setup over the phone. If all of the aforementioned questions are answered to your satisfaction, it is worth scheduling a visit. Now you have made it through the first major hoop in screening your PMD prospects. It is important to do your research here because you are, ideally, going to see your PCP once a year to stay on top of things. If you wait until a busy season like the end of the year to squeeze in a physical, you will not get to the clinic in a timely manner. Leaving a 6-month calendar reminder on your phone to schedule a visit later makes this part easier.Let's say you make it to the clinic in a reasonable time frame, like within a month or two of your initial phone call, for a regular physical and you are chilling in the waiting room. At this moment you are more likely to check your crypto wallet or social media newsfeed than to think up some questions for your doc. In the next episode, I'll fill you in on simple tips and tricks to get the most of your routine visit even if you're fit as a fiddle.Stay tuned and subscribe to Friendly Neighborhood Patient for more wonderful and practical guidance! This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Calling all patients,Think of your healthcare like your bike. A bike suiting someone who's 6'3” and 280lbs wouldn't work for someone who's 5'5” and 140. The purpose of a bike or a car of course is to take you from point a to b—that doesn't change. But not everyone should ride the same bike, the same car, or have one-size-fits-all medical care. The problem is that various companies and governments are trying to replace and reinvent healthcare when the equivalent of applying some WD-40 and switching the chains is a better solution for most people.Patients need guidance, straight facts, and brutally honest truths about the medical field. This is a direct, incremental solution rather than having a knight in shining armor swoop in and innovate everything for us in a timely manner. There are many issues with our current medical infrastructure to talk about but I'm here to teach patients all the tools and tricks to pedal through our healthcare system with ease. My experience with running a medical clinic and telemedicine platform is going to help us cover practical things like how to find a new primary doctor, learning how to be prepared for any kind of medical visit, understanding your health insurance, and knowing why you should care about big-picture developments like genetic therapies and CRISPR, for example.As a patient, you deserve to be an advocate for your well-being; you have much more power than you realize. Knowing simple tips and lingo is the grease making all the gears of our evolving healthcare ecosystem turn well. Subscribe to Friendly Neighborhood Patient and learn how to be healthcare savvy in 2022 and beyond! This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com