Thursday, December 3, 2009

Just Say No

Things are tough all over. Occasionally I get patients asking me if I'll forgive their appointment co-pay. Usually I can't, because most insurance contracts forbid it, and because I'm trying to stay afloat, too.

So today I had a lady tell me she can't afford her $25 visit co-pay, and could I PLEASE write it off? She used the "I need the money more than you do" line.

I know she has legitimate financial hardships, but I refused.

Why?

Do I need the $25 that badly?

I did it because she smokes 2 packs a day. And ADAMANTLY refuses to quit.

Let's look at this:

The average price of a pack of cigarettes in the U.S. right now is $5. This varies by brand & your state taxes, and whether you buy them by the pack or case. But roughly $5 a pack.

So for her, that's $10/day. Or $300/month. Or $3600/year.

I told her that. If she quits smoking, that would be like her getting a $3600 annual raise, without any additional taxes. Ignore the health benefits, just look at the money alone.

All that money for making one life change. That would help her financial situation A LOT. It's a hell of a lot more money than making a $25 co-pay once or twice a year.

She got pissed off and left. Told me that I "don't understand".

She's right. I don't.

For an excellent post on drug co-pays from the pharmacy view, check out this one from The Angry Pharmacist.

43 comments:

amy said...

Dr. Grumpy:

I lead a psychoeducation group for men who batter their wives. It's a 40-week (and not long enough in my opinion) state-mandated course that each of the men has to pay for, with cash, $50/week. I have many guys who want us to cut them a break--they're unemployed, they have to pay child support, their court fees are so high, and so on--and like your patient, if they smoke, the answer is always "no".

Grumpy, M.D. said...

Thank you, Amy. I'm glad others agree with me on this.

Mr. Condescending said...

I bet that even if she quit smoking, she'd still be broke and that money would be spent with nothing to show for it.

Susan said...

I totally agree. As a (long time now) ex-smoker, we *do* need to hear from medical professionals how very important it is to quit. I am now one of the medical professionals giving that advice. I quit back in 2002 when I became licensed.

oddharmonic said...

The $40 office visit (self-pay, no insurance) to see my family practitioner a few times a year seems insignificant compared to $3600/year for cigarettes.

But as a nonsmoker, I don't understand why she hasn't quit yet.

nRT said...

Totally off subject, I am officially a groupie, I got my "Dr.Grumpy Groupie" Tee shirts and bumper stickers today. I will wear it with pride.

Grumpy, M.D. said...

nRT- Thank you so much!

Celeste said...

She should try asking the store to give her the cigarettes for free if she feels so entitled to getting something of value, for nothing. I'll bet no one understands.

How incredibly insulting to be told that the service you provide is valuable, but they don't think you're worth paying.

Amanda said...

Isn't it nice? You should work for free and she shouldn't give anything up.

I can't get over the balls these people have. I would never consider asking my doctor to waive his fee.

People still honestly believe that MDs make a fortune. Unless you're doing plastic surgery and getting paid cash, the money isn't there.

Anonymous said...

You should have told her youd take 5 packs of cigaretts as payment...

C. said...

I'm surprised she can breathe with a 2 pack/day habit.

I don't smoke and there are days *I* can't breathe.

Then again, I've got asthma

hannah said...

My mother's a carton a week smoker. One carton = 10 packs. Roughly $50 after taxes. That's only $200 a month. Grumpy, you should tell your patients to switch to buying cartons over individual packs to save money. ;)

/not really, but man, my mom comes from a different era in regards to cigarette smoking...

Gert said...

Good for you!

charis said...

My father smoked until it killed him; "Well, yuk yuk I 'd rather live to be 80 smoking then live to 90 as an uptight a******."

He died at 62, but it took 2 excruciating years, most of which was spent on the 4th floor oncology ward. I never asked anyone with my dad's illness "How do you like it now, Gentlemen?" but believe me NOBODY on the 4th floor was lifting their head out their emesis basin to proclaim the benefits of smoking.

I had a hard time forgiving my father even though I know that habitual smoking causes the brain to behave as though smoking were necessary to life.

That's why it should be effing illegal. Anything that trains people's brains to commit slow suicide should be.

My dad always quoted Rush Limbaugh as saying smokers cost their fellow citizens less money through dropping dead early and not being a drain on the system. Well, my father blew through his 1 million dollar insurance cap before his second round of consolidation chemo. Not a sterling example of saving your tax dollars.

Anonymous said...

I'm with you all the way, Dr. G! Why should you and your employees subsidize her insistence on killing herself (and possibly others, through second-hand smoke).

Sandra

Anonymous said...

Thank Heavens Dr. Grumpy was 'on the ball' there and told her plain and simply 'no' but was willing to work with her. It was plain rude-- to think that a patient thought she could get the diligent service of a trusted physician for no payment at all, that she wasn't even willing to work with considering quitting smoking, in the best interest of her health.

What I'd like to know is what she meant by 'you don't understand'; what was it that you did not understand?

Anonymous said...

I quit in 2004 after smoking for roughly 12 years.

3 years before that, in 2001, I quit injecting heroin into my arm. That was much easier than quitting smoking. (Really--harder in the first couple weeks, but easier and easier as the months passed.)

I'll be 9 years sober in January, but smoking has never been far from my mind. I started smoking again in February. Not nearly as much as I used to, but enough for it to count.

The sh*t is evil. I really hate it, on myself and especially other people, but I have a special sympathy for the die-hard heavy smokers.

It's disgusting, nonsensical, and destructive, but until nicotine has had you by the balls, please try to judge us a little less harshly.

Besides, Mr. Condescending is right--when we're determined to waste our money, we easily find other ways to do so.

Anonymous said...

Wow, and I thought it was just us veterinarians that had clients like this. Welcome to the club Dr. Grumpy. I look forward to seeing you at next month's meeting. ;-)

Anonymous said...

This reminds me of the people who used to ask me for money. They would claim it was for their baby. You know, for diapers and/or formula.

If they were smokers and had bought cigs, I would turn them down flat. "If you got enough for cigarettes, then you have enough for formula and diapers." They would, of course, cry poor. I would always tell them to take the cigs back so they would have enough money for the baby. I was not popular.

I smoke. I know it is slowly killing me. I know that I should quit. However, I always bought my cigs AFTER I was sure that my children had what they needed.

I have borrowed money to buy cigs. I always told the people what I wanted the money for, instead of using my kids as an excuse. Most people just appreciated the honesty.

rlbates said...

I just popped over from my reader to tell I love the stance you took only to find the comments are great too. :)

Anonymous said...

I don't think copays should be waived...however, if a patient is going through a tough time, I think it would be decent to allow a payment plan (pay half now... bill for rest) If they been a long time patient...new people? Give them directions to the clinic...
Behavior has consquences.

I am an unemployeed, non-cobra qualifying, medicaid receipant. I should apply for ssd/ssi but I want to work. My medical expenses are so high...I cannot afford to work at a supermarket for min wage and lose medicaid. And I think that sucks. I am very thankful for the cheap medicaid copays.

But some of my docs do not take medicaid and I have been self pay with them. I have payed them a little, and put the rest on account.... I will have a job soon I hope.

Anonymous said...

I didnt know people could ask to waive their co-pay! I talked to a guy today that said he wanted to fly down to have a complete "over-all" Be admitted to the hospital and get fixed. He said someone from our place told him he would need $500.000 cash to do that, (like anybody said that) And he wasnt going to pay more than a co-pay. So he wanted to talk to the president. So I connected him to the White House. (just kidding on that last part) But he did say all that. geeze. Signed: Hospital and big clinic switchboard operator.

Anonymous said...

And she is probably one of the idiots who think everyone should have "free" health care paid for by me

The Bus Driver said...

I have never considered asking anyone to waive the cost of anything even in light of my hardships in making ends meet.

If i ever ask for any consideration (waiving co-pays) it would only be temporarily until the next available pay period, in which case, i would walk in that day with the payment in full.

Anonymous said...

This just happened this evening:

"Why do I have to pay $1.10? It supposed to be free, I have MediCal. Man, insurance companies are just greedy bastards!"

"No, sir. MediCal is a welfare program funded by tax dollars. Your particular situation does not qualify you for 0 copay."

"That's just not right. Can you ring me up these items as well?"

(in the cart I found 2 12-packs of Natural Light and a bottle of Crown Royal)

"Sorry sir, please bring those items up front. I cannot in good conscience sell you Vicodin and alcohol together."

"$%^*! $*@*&(@)"

Qex said...

I know a couple with a holiday home out on the lake, accessible just by boat. They didn't have one, so they put their heads together and thought... 'Hmmm - if we quit smoking, we could put the money towards a monthly loan payment on said boat.' Which is why they call their boat the 'Six pack'; in memory of their former habit.

Anonymous said...

in response to charis' comment, I'm in pharmacy school and the one thing they adamantly preach about smoking cessation is that the patient has to want to quit. no amount of whatever you throw at them will help unless they have the drive to do it. but one thing that has always stuck with me is something we were told to think about when the patient says that they're going to die anyways.


"yes, but you can help control the state in which you die."

I think if more people realized the end was as horrible as it was for charis's dad, it might be more sobering. who knows. I'm just hoping the smoking vaccine comes through.

Anonymous said...

The same people that ask you to waive their co-pay come straight to the pharmacy and expect the same thing. No Sir...Nexium is not a $4 generic (despite what your neighbor's older sister's second cousin told you) And to the awesome parents of the world...yes... you could afford the few dollars for your child's medication if you didn't have that shopping cart full of useless crap!!

Maha said...

I get people asking me for free tylenol, ibuprofen, gravol - just generic otc drugs when they have giant starbucks lattes, cigarettes, cell-phones/electronics because "I'm fresh out of money". Well guys and gals, if you can afford a brand spankin' new iPhone to match your ciggies, you can just as well splurge on a brand new bottle of tylenol. And stealing supplies from the suture room is NOT cool... EVER!

I like how you tried to actually tried to provide her with a solid incentive for quitting.

Anonymous said...

How much does 2 shots of scotch with a little soda cost now days? Is drinking ourselves into oblivion acceptable? Do these patients also get told the same line you use on the smokers?

First, I can't imagine asking a Dr. to waive the co-pay, but, if they do that, then I hope the alcoholics don't get theirs waived anymore than the smokers do.

Don't forget the obese people. Little less hamburger would do them good and put a co-pay in your pocket. For that matter if the diabetics are non compliant and spending money on chocolate bars and ice cream don't give them a break either. That heart attack guy eats way to many steaks and they are expensive. He needs to be reminded of that if he doesn't have co-pay money.

Slippery slope doc. I think you should absolutely expect to be paid your co-pay, but, I think you should expect it regardless of a persons short comings. we all have some lifestyle habit that qualifies as unhealthy. If we didn't, you most likely would not have to worry about co-pays because there would not be many patients. We would all be healthy as heck and one day at age 100 just fall dead.

River said...

$5 a pack for ciggies? Over here in Australia they're from $9 up to $15, depending on brand and pack size. Sooooo glad I don't smoke.

Anonymous said...

i went from 30 a day to none over night. my then girlfriend refused to marry me unless i quit. i think it's called incentive. took 5 years for the cravings to stop but have never touched one again since that day. been 37 years now. o yes, and we have been divorced for some time.

ERP said...

Did you explain that she could have afforded the 25 bucks if she quit smoking or did she not want to hear that?

Grumpy, M.D. said...

ERP- I explained it in detail, even showed her the math.

Anonymous said...

Hell, when I can't afford the co-pay I just postpone the doctor's visit. The one thing I *am* glad about is that the hospital ER will bill you the $100 non-admitted co-pay... had a cat bite that needed antibiotical attention and I only get paid once a month. I probably could have waited a day or two to see if it got really bad, but I did not want to have to be admitted (with my insurance I pay 10% of all hospital procedures).

Of course I'm fat and asthmatic. If I would just lose 60 pounds and exercise an hour a day, I probably wouldn't even have to go to the doctor. I could save $100/month just not buying food. It is definitely something to think about.

Smoking is a luxury, just like having a cell phone or drinking alcohol or driving a cool car. No sympathy from me if you won't give up your luxuries for your necessities.

Anonymous said...

Two of my grandparents smoked for many years but quit before I was born. Both became oxygen-dependent as they aged as a result of long-term lung damage from smoking... even though they had quit decades ago. Lung cancer is a horrific death, but emphysema is no picnic, either.

Re: wasting money - a few years ago I found myself as the plaintiff in small claims court, chasing a client. One case called before mine involved the landlord of a low-income housing program. The family she was evicting had my sympathy until the landlord mentioned that one of the problems in addition to the unpaid rent was the tenant's illegal cable TV dish (this building didn't allow a dish for esthetic reasons).

If you're living on the edge, money spent on non-essentials like cable, cigarettes, BlackBerry, etc. adds up quickly. The problem is that most people haven't done the math and don't have a household budget. Maybe Dr. G caused this woman to start thinking about her spending choices.

Anonymous said...

Sorry, I disagree. I'm not even reading the other comments before putting down my thoughts:
I hate smoking!!!!
I think nutrasweet (diet coke ring a bell?) is a toxin poison.
Try giving up anything you're addicted to (me- food) forever!!! Not just a day, a week or cut back. Honestly I wish smoking (all kinds) fake chemical sweeteners and hydrogenated food would disappear in one push of a button.
But that's not going to happen. And no matter how many people believe that diet coke is bad for you, you're not giving it up for anything.
Just being honest.

Meghan said...

There is a difference between diet coke and smoking. Whatever you may believe, there aren't any reputable studies showing the dangers of current artificial sweeteners. However, there are hundreds of studies that link smoking to a myriad of serious health concerns. As far as the comparisons to obesity and spending too much money on food - I have a BMI of 20 and probably spend more money on food than many obese people - healthier food costs more than junk. People have to eat, you cannot just cut out food to lose weight; you can, however, cut out smoking with no ill health effects - that's the point.

Anonymous said...

Dr Grumpy, could you buy me a pack a smokes? Pleeeeeeze?????

Anonymous said...

People have their reasons for smoking. Smoking controls my ulcerative colitis. Stop being so self-righteous about smoking.

—g.

Anonymous said...

My dad refuses to quit smoking (two packs a day as well) and he bitches about things such as the price of college now (since I'm starting soon) and when my mom buys thing, usually a $40 textbook for me on anatomy and physiology that I'm actually going to use and enjoy.

He's been smoking all my life and if he quit when he did, we probably wouldn't owe so much money on everything as well as struggle through college fees.

remus-chocolade said...

Let me just say, USA is a great land for smokers!
Here in Norway it's roughly 10-12 $ a pack, but we usually skip over to Sweden and get it for 5-6 $ a pack. That's quite a difference for just over an hour's drive...

Anonymous said...

I can't imagine asking to have my co pay waived but have asked to pay it on my next payday. I absolutely understand not waiving copays but I am having difficulty with the amount of people that are very judgmental about smokers. I quit 8 years ago and haven't wanted one since, however, my husband has not been able to quit for more than a month or two at a time no matter how much he wants to logically. A pack will last him 2-3 days. I would love for him to be able to quit but I DO understand the difficulty and he is an incredible man. Does the lady have a right to be ticked off...absolutely NOT, however quitting any addictive habit isn't easy no matter the circumstances. When a person feels judged or less than they do tend to react defensive, not sure if that felt that or just selfish. Most ppl that struggle with addictions that I know feel guilt and less than. I know, I have worked with addicts of all kinds for almost 10yrs and am also a recovering addict myself.

 
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