A doctor dreams of moving to Canada

The challenges of practicing family medicine in the United States.

This week’s Sick Note interview is relevant to anyone who has been to the doctor, or wants to go to one but can’t. Ever wondered why primary care appointments are so hard to get, or why they’re so short when you do get one? Or laughed when an ad or piece of official advice tells you to talk to “your” doctor? (Who?) Today’s post might help you understand.

We’ve talked before about how the American healthcare system, or lack of one, makes it hard to treat health problems before they get too serious—how so much else about our rotten society creates those problems, and lets them fester, until they’re much harder to fix. The ER nurse we heard from in January talked about the difficulty of treating patients who come in with chronic health needs but don’t have a primary care doctor—people who “could definitely benefit from healthcare, but not mine, unfortunately.” The cardiologist we heard from in February talked about the “nihilism” he feels from being unable to actually address the root causes of his patients’ illnesses.

A huge part of this problem is the immense cost of American healthcare. If you don’t have insurance, you’re much less likely to go to the doctor when you have a troubling symptom; if you do have insurance but it has a high deductible, you’re in the same boat, or you might avoid care that would actually be covered because you’re afraid of cost. But there’s also problems with the actual practice of primary care, even when you do decide to go. Doctors’ schedules are packed; most of the time I book an appointment with at my primary care provider, I’m seeing a nurse and not a doctor, anyway. It can take weeks or months to get an appointment with a new provider.

Today’s interview is with Harrison Kalodimos, a family medicine doctor in Seattle. We talked about the burdens that our healthcare system places on doctors like him, and how it makes it difficult for him to practice medicine well. Things like insurance reflexively denying requests for imaging procedures (like MRIs), or the fact that he has to consider what sort of insurance patients have and whether they’ll even be able to afford the drugs he wants to prescribe, make it harder for him to do his job.

A couple of key bits from our interview: I asked Kalodimos about the time he spends fighting insurance companies over treatment for his patients, and his answer was interesting. Kalodimos has a full-time assistant, whose job is essentially fighting with insurance companies to get coverage for drugs, procedures, and so on. This is the kind of waste that’s inevitable under a system like ours, where you have payers fighting providers over what they’ll cover and what they’ll pay. As Kalodimos noted, all of this just adds to the cost of healthcare, in the form of insurance premiums. We’re paying insurance companies, who pay doctors, who pay people to fight the insurance companies. Who could call that efficient, or even faintly sane?

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A great example of the sort of petty insurance bullshit that doctors have to deal with comes at the end of the interview. Since the pandemic started, telemedicine has been a vital way for people to get some kind of care, imperfect as it is, without risking their safety. But medical billing is incredibly complicated, and telehealth is no exception. Kalodimos said that if he can only talk to a patient over the phone, without a video component to the call—for example, if the patient is too poor to have a smartphone with video capability, let alone a computer—that makes billing for the visit harder or impossible. Coverage varies from insurance plan to plan; this guide to commercial insurance coverage for telehealth from the American Occupational Therapy Association notes that some private plans will only pay for visits that have both video and audio elements, even since Covid hit. Medicare is allowing audio-only calls to be billed in the same way as in-person visits during the pandemic, according to the American College of Physicians. But the point remains: With American healthcare, it’s never just as simple as a doctor treating a patient. It’s no wonder Kalodimos dreams of moving two hours north to Canada.

As always, this interview has been edited and condensed.

Harrison Kalodimos: I'm a family doctor up in Seattle, so that means I do pediatric, adult, geriatric and women's health. It's kind of a full spectrum of primary care. Across all the ages, I would say probably the only two things I don't do are surgery, and I don't do deliveries anymore, though, I did do those in the past.

Sick Note: I feel like this idea of family medicine is a little undervalued, perhaps, in the US.

Harrison Kalodimos: In the United States, there's kind of a particular history of it, it's actually a profession that is pretty recent. I think in the 60s or early 70s is actually when the specialty first came about, specifically because of different regions in the United States not having access to a full spectrum of care. So they would have an internal medicine doctor that can see adults, but they didn't know how to treat children, or they could see adults, but they didn't know how to do women's health. And so it's addressing the disparity when it came to the full set of services, and particularly rural or urban underserved settings. And so the specialty attracts people that were mission oriented for particularly that reason. 

But you're absolutely right, that is often the case that when you have complex medical needs, even if you have like one or two chronic illnesses, you end up seeing a pretty wide variety of specialists. And it's difficult to coordinate care between them. It's often very expensive, because either there's a higher copay associated with seeing a specialist, or they just don't accept your insurance, but they're the right specialist for you, so you pay out of pocket. It's pretty exhausting to be a patient in that setting. Part of the reason that I went into family medicine is that I wanted to be able to say, whatever needs you have, I will do my best to meet them. Now, it doesn't mean I can do everything at the exact same level as any specialists, but my patients get that and they say, “getting my rheumatology care from you, versus not getting it all because I can't afford any of the rheumatologists in this area, I'd rather get it from you.” So I wanted to be able to provide those services at the cheap or free access level that primary care is often afforded to people who have insurance.

Sick Note: That seems like a neat sort of cheat code for people with insurance that prefers primary care to specialist care. Again, certainly my experience has been seeing specialists for very minor issues, like having to go to a dermatologist because I've got a weird thing on my hand or something, and it's very stupid to have to wait so long and then pay a specialist copay for that.

Harrison Kalodimos: Oh, absolutely. No, the wait periods are really insane, which is kind of comical to me whenever I hear somebody that obviously doesn't have a lot of experience in the American medical system who'll kind of say, "It's terrible to be a Canadian, because you have to wait three months to get a knee replacement." And meanwhile, my patients are saving up for six to 12 months to afford a knee replacement. A wait is a wait regardless of [whether] you're waiting to save the money, you're waiting for an appointment to become available, or you're waiting for insurance authorization, or some big stack of paperwork to get filled out by me and my colleagues until something gets approved. 

A great example of this is MRIs, which is, the piece of equipment is not cheap. And it's a pretty nice piece of technology. But you go to Japan, and they're incredibly affordable. It's not that the physical device—the technical training of the person running the thing, the technical training of the person reading that the film afterwards, is no different. But their market is different. And that kind of makes the difference between getting an MRI on demand, and waiting for three months of insurance paperwork before you can get your knees scanned.

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Sick Note: Are there any procedures, or really any kind of like particular insurance hurdles that are especially frustrating as a doctor, if there's anything where you need it, you're like, "ugh, I have to do one of these now?” 

Harrison Kalodimos: I would say that imaging does tend to be one. I would say that I'm similar to many, at least other family medicine doctors, and probably the most primary care doctors, that we get that the expense of what we order is going to be dispersed amongst all payers. And so if I am overly eager to order MRIs on every single patient that comes through the door with the slightest bit of knee pain, all of our premiums are going to go up, all of our co pays are going to go up. I get that, that with the way that our current system is structured, that's going to come out of our pockets. And so I'm very judicious with these things and kind of pride myself on being really good at doing a physical exam and appropriate use of lower cost imaging modalities. 

That being said, when I do have the judgment to say, I think that actually it'll be clinically useful to get this type of imaging, and then to have somebody with either no medical training, or a person who was formerly a doctor and burned out and went to go work for an insurance company to be their prior auth person, and then have them undercut my clinical judgment... It's difficult. And not to say that I have such a huge ego, that I am absolutely 100% right all the time, I am more than happy to be clear in my reasoning about why I'm ordering things. But what I've experienced is oftentimes, the strategy here is deny, and then see how frequently, or the aggressiveness with which the doctor will pursue that.

And then using that as the threshold of necessity, because if that's how we're going to determine how necessary something is by like, how willing a doctor or patient is willing to badger you for the thing, that's not going to be equitable care. That's going to bias towards somebody that has a concierge doctor that only sees eight patients per day, or somebody that has kind of a privilege of a lot of spare time on their hands to call up their insurance again. Which is not the case for my patients with three jobs and four chronic illnesses. And so to answer your question, one area where I see that is, is in imaging and how these denials are used to basically save them money.

And part of the reason it gets under my skin, especially is because I tend to approach my analysis of these things with an equity lens and say, how does this system kind of bias towards one group of patients or another? And that just makes you upset, and then I go home and have a sleepless night over it, because I'm all riled up over it. Getting referrals for certain types of surgeries and certain types of specialists—for a long time, bariatric surgery required so many hoops to jump if you were a Medicaid patient.

And once again, I’m not somebody that's like “oh, we have to do surgery for every single problem.” I'm very prudent in who I would recommend that for. But then when I do, there's this like, incredible infantilization of the patient, all these hurdles that they put up, and this idea that if you're not willing to jump through all these hurdles, how much could you possibly need it? And it's like, well, there's a lot of factors that go into whether somebody has the time, space, and energy to jump over hurdles, and medical necessity is not the driving force there.

Sick Note: It's interesting, because I feel like I've encountered this idea of the patient who doesn't have time to chase up this stuff. But the idea of a doctor who sees a lot of Medicaid patients, for example, and packs their day with people, is necessarily going to be more busy and have more of this stuff to deal with—it's interesting to think of that in an equity way, as well. 

Harrison Kalodimos; Well, it's part of the reason it can sometimes be difficult to recruit doctors into practices that see a lot of Medicaid patients. So are you familiar with the term FQHC, a federally qualified health center? And so I love my colleagues at federally qualified health centers, I think they do phenomenal work. I do feel like they sometimes have additional difficulty recruiting doctors, and not for lack of passion to do the right thing amongst the medical profession. But there's this understanding that when you go into that world, there's going to be all these logistical barriers and hurdles. And, everything just makes life so much harder for your patients and you internalize that, you know, you share that frustration. And it burns you out. And it's just, it’s tough to see on a day-to-day basis. 

Sick Note: Do you feel that you tend to get more trouble from helping Medicaid patients, or from private insurance patients? Are there more hoops to jump through? 

Harrison Kalodimos: It's one of those things where you have to kind of check the way it biases you as a provider. Because when I'm looking at my medical record, I see what insurance a patient has right at the top there. And the sad fact is, that's a necessity because when I'm, for example, seeing a patient with diabetes, and there's this really excellent new class of medications called a SGLT2 inhibitors, Jardiance is probably one that you've heard of.

Sick Note: That's one of the names we laugh at every time the ad comes on TV.

Harrison Kalodimos: And the thing is, these are good medicines, but they're incredibly expensive. And I look and I see that somebody has some type of private insurance, and I'm like, “Oh, well, I can prescribe this for this person, and it's going to be quick and easy.” I talk about some of the risks and benefits of the medicine and we kind of have a clinical conversation about whether the patient wants it. Versus if I have a patient with either Medicaid or who’s self pay—or has Medicare, my panel is very large on Medicare patients who have different sort of prescription drug benefit than either of those two.

And so, it becomes this whole additional conversation that’s like, well, I've got to talk to the patient about, these are the kind of expected costs with this medicine, so call me if your bill is over such-and-such amount of money, and then we can talk about maybe you can do the copay assistance program, versus the charity care through the company, versus using a GoodRx coupon or some of these other kind of coupon services. And then if I do try to do it through their insurance, I've got to submit a whole document about every other thing, I've got to prove that tried all the worse medicines, before I try to prescribe the thing that I actually think is the best for this patient.

I think that for most of us, “do the right thing” is a really powerful driver. I only speak for myself here, but I got into this profession to do the right thing. It feels good to do that, and it's super rewarding when I can practice that. But then you’re also, like, I'm running 20 minutes behind right now. I've got eight more patients to see before the end of the day, I was at the office until 8pm last night, and my wife says she misses me. And all these things kind of stack up in your mind, and it just distracts from the mission here. The mission is this, like, fight against disease and death, and then you're kind of loaded on with all these other things that are just distractions.

Sick Note: I have a particular hatred for the copay assistance program thing for these new specialty drugs, because it just pisses me off. I just think, will you just please make the drug cheaper? Just make it like, actually affordable, because it's so obviously just another set of hoops to jump through, another barrier that people can fall at, and they're going to. It drives me nuts.

Harrison Kalodimos: Right. And I'm at a practice where we're constantly having to shut down to new patients, because we're just packed. Seattle's an incredibly wealthy region, we have a lot of privileges here in Seattle, and yet, to get a primary care provider here is incredibly difficult. And, patients are like, it's getting harder and harder to see you. And I'm because I'm trying to balance taking on new patients, because people are on these wait lists for getting a PCP for months and months and months, and making sure that for my current patients [if] they do want to see me, they can do so within the month, at least. It's a really tough balance to meet the needs of your current patients, but then also meet the needs of the community,

Sick Note: Can you estimate how much of your day you spend dealing with sort of insurance bullshit and other stuff like that instead of patient care?

Harrison Kalodimos: Well, believe it or not—maybe a different framing for my particular situation is that I have a full time staff member who is basically at my side all day, and pretty much her main job is to fight these insurance fights for me. There's kind of multiple ways of doing this, right—one is to just take your time as a provider to do these things. The other thing is to take a pay cut, basically, give that money to somebody. Take a pay cut or, I mean, I think what ultimately happens is that medicine just becomes more expensive for everyone. Having an amazing assistant, she's such a hard worker, who just spends all day finding the insurance companies on my behalf, the patient's behalf, and she's my teammate, she's my peer, she doesn't work for me. She's just like my partner in crime here, because it's such a necessary position. It's sad that it's necessary, but it is. And I guess I do, like, I probably spend two hours per day, just kind of doing paperworky kind of things. But I would say that my burden is actually much less than the average person, because I have the assistant. But that salary comes from somewhere, right? That salary is part of your premiums, it's part of your co-pays.

Sick Note: It's just so funny—ultimately, we are paying higher premiums so that someone can be employed to fight the insurance company.

Does it ever make you want to go and practice medicine in another country that has, like, a healthcare system?

Harrison Kalodimos: Oh, I am two hours from Canada. I think about it constantly. Vancouver is a lovely city. The mountains out there are amazing. Yes, I absolutely think about all the time. And yeah, I mean, not that they're without problems. I follow many Canadian doctors on Twitter, and some of the difficulties they've had in certain provinces are very upsetting. Some of the issues in Alberta recently have been really troubling. So, yeah, not to say that it's just magical over there. But yeah, I go to this conference every year called the Best Science Medicine [Course] that's run in Vancouver—obviously it was cancelled this year for COVID. But they would, with all their medication recommendations, they have these price lists, which are just the Canadian price list. And they just know exactly how much the medicine they recommend is going to cost. And it's like, a fourth of what my patients pay, and it's the same medicines.

Sick Note: I've seen a lot of coverage of how primary care doctors in general have suffered a lot under COVID because of people delaying care and so on. [Has] that been the case at your practice, whether it's been difficult financially, or even medically, getting people to come in during COVID?

Harrison Kalodimos: The structure of how we get paid is really messed up and it's always been messed up, but I think that this year just really emphasized the extent to which it's messed up. [...] These big [hospital] systems definitely recognize that part of building up this pool of primary care doctors is driving these referrals for elective procedures, and those elective procedures are where the good margin is, and that's where they make all the money.

Some groups have gotten into trouble with this, because they say, generate more billing, we don't care how you do it. So then doctors end upcoding, which is to say that you're doing something more complex than what you're actually doing and, and that leads to big lawsuits. These systems end up losing a lot of money to paying these fines and paying for legal fees, because they get caught doing this all the time.

I guess another really frustrating thing is that there are some doctors out there that commit fraud, I'm not going to deny that that happens. And it's easy to be like, I'm not one of them, so why should I be punished? But one of the ways that this comes out is the necessity of an in-person visit to be able to get any reimbursement from insurance provider. So, if you call me up and say, “Hey doc, Lexapro is working great for me, just send in another refill for me,” I'm happy to do that. But the thing is, even though I take the time to like, look through your medical record—make sure that's up to date, make sure that you're kind of caught up on any screenings and making sure that I'm checking that you're not having major side effects with it and that it's still the appropriate medicine, for the minimum effective dose that will achieve what we want to achieve with this medicine. I don't get paid for any of the work unless it's in this specific context of an in-person visit. 

And this year, in particular, they said, well, okay, you can do like telemedicine visits, and so we had this huge explosion in video visits. But then there's this really absurd thing where if my patient is too poor to have a phone with a camera on it, with a high speed internet connection to support that, in a private space, in a residence, to have a private conversation with a doctor, and [they] say, the best thing I could do is just a phone call—don't get paid.

Sick Note: That is so mental.

Harrison Kalodimos: Isn’t it? So I'm talking to this really sweet 95 year old patient, like, you've got to get your grandkid over there to like hold the phone for you with your iPhone to help you out here because the, the clinic infrastructure on which I work doesn't let me just make some phone calls and just do some judgment calls based off of a phone conversation. 

For some things absolutely, if somebody is like having really bad abdominal pain, and I'm concerned that they have a condition called diverticulitis or appendicitis, I want them to come in because I want to push on the belly, I want to figure out if there's something dangerous here. It's not totally arbitrary when we do ask people to come in person, a lot of times there are some some legitimate concerns that we do want to address with that person you just can't do over telemedicine. But a lot of it is just totally arbitrary based off of these billing practices, Which is the question: How much would we actually lose in fraud if we just loosen up these regulations versus how much are people and patients punished for those things?