A middle aged patient whom I have seen in the past for benign palpitations called today because of atypical chest pain. Although I have criticized the overuse of nuclear imaging studies, and probably order the fewest of any cardiologist in the city, there are times when they are appropriate –this was one of those occasions. Symptoms did not rise to the level of an invasive angiogram, but could not be ignored either. Further diagnostic testing was needed.

How do I know it was appropriate for this patient? Because I called her, took a history, and assessed the situation. The history of present illness, past medical history, risk factors and essentially all the information needed to decide on further testing was available with 20 minutes of time and a phone. A side bar in this case is, unlike my law colleagues, the one-third of an hour of time spent was free.

To my surprise, a few minutes later my medical assistant informs me her insurance will not authorize the stress test until she is seen in person. Really?

This patient will have to come in and see me. I will take the same history. The examination will undoubtedly not change anything (it was normal last year), and I will order the same nuclear stress test. Now, the bill will include a bill for an office visit, an ECG and the stress test. If my partner in my new cardiology group saw the patient, it would be a new patient visit, ECG plus stress test. An extra two hundred dollars in billing plus the inconvenience to both patient and doctor arises from this silliness.

What should have happened in this case? The patient comes in for the stress test, the supervising doctor gives a preliminary read of the stress ECG, and I would have called her the next day with the imaging results.

It is dumb, inefficient and borders on the anger-inducing to have an uninformed profit conflicted corporation making decisions on patient care that in this case increased the cost of care. Did the insurance company have a previous doctor-patient relationship, or did they discuss the symptoms with her?

Always pointing out problems, and never suggesting solutions gets old, so I will not perpetually drone on about the inadequacies of our present day delivery system.

To me, good answers usually come in simplification.

I am often slow to understand things, so someone explain why paying an internal medicine doctor, cardiologist or surgeon cannot be like the treatment plan for my root canal specialist — in which he swipes my credit card for $950 for a 45 minute procedure. No business office, no rejections of payments and no uniformed constraints are placed on the endodontist. Yes, it seems expensive, but the tooth hurt, then it didn’t, and he went to school, studied hard and learned an important skill that enhanced my life.

Yes, I know health care costs for hospitalizations get catastrophic quickly, so obviously there is a role for insurance of some type. I get this. But why does 93651 — the code for catheter ablation — which takes longer than a root canal to do, way longer to learn, and is far more dangerous to the patient pay $300 less? Additionally, cardiologists have to hire a business office to file the paperwork, and appeal the frequent rejections.

Seems that a starting point would be to make healthcare more like real economics.

Also, like I learned by paying $950 for a preventable dental problem, patients who pay the doctor with a Visa card are surely more prone to discover the benefits of healthy living behaviors.

I better stop.

John Mandrola is a cardiologist who blogs at Dr John M.

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