In clinic a week or two ago, I had a new patient. He wanted a prescription for insulin so that medicare would pay for it.
I started asking the usual doctor questions. How long have you had diabetes? What is your dose? Past medical history, history of present illness, allergies, family history. First I tried to understand which kind of insulin and what dose he was taking.
He responded with anger and impatience and wouldn't tell me.
I said, "This feels hostile."
He said, "It IS hostile." and he left.
I thought about charging for the visit, which I could do. But he might have a deductible and it would just make everything worse. I thought, well, maybe the pharmacy can help me understand.
I called the pharmacist. The insulin that this man was on is available over the counter. I did not know that any insulin is available over the counter. This patient was at times difficult in the pharmacy; the pharmacist said that I should not take it personally.
I wrote the patient a letter. I explained that for medicare to pay for the insulin, I have to document in the chart that I am monitoring his diabetes regularly. There are guidelines for labs and physical exam and counseling and eye exams and blood pressure parameters and so forth. I have to write the dose on the prescription. If he wants medicare to pay, we have to meet their requirements.
I also said that I did not know that insulin is available over the counter, so the visit confused me from the start. I said that if he doesn't want monitoring, he can continue as he is doing.
I wrote off the visit.
A man was at the counter scheduling a visit a few days ago. He winked at me. I didn't know who it was, but I was surprised at a friendly wink from this person.
He came in this week. He answered all my questions. I explained the diabetes guidelines. His blood pressure was too high, but I tend to ignore that on the first visit, particularly if it is someone who is not very fond of the medical profession. He is willing to do the lab work. He is adjusting his insulin, as he is having too many lows.
He's coming back in a week or two, to go over the labs.
I am so surprised.