Follow up after annual physical

[automotiveRN67]

This question is for nurse practitioner's practicing in primary care.

Background: I am healthy, slightly overweight, and just shy of 50 years old. I have been on losartan for 5 years, and my blood pressure is well-controlled. I am a nurse practitioner. I don't work in primary care.

My insurance (as does everyone's, I think), allows for an annual physical exam with labwork that has no out-of-pocket cost. I have an HSA, so any other visits cost the usual rate.

I haven't had my physical this year, so I had a colleague write for losartan for me. But I still want my labwork done.

I contacted a primary care office in my area. They told me the doctor will not prescribe any refills at the first visit for a new patient, and will require a follow up for lab results. Then they will refill my losartan. This will cost around, $65 out-of-pocket. I quizzed the secretary, and found out that if he adds a medication, like..say, a statin, then he has to see me every 6 months.

Of course, I could go to the first visit, request my lab results, and bail the following visits. But that isn't right. Neither, in my opinion, is it right to charge someone for a follow-up on a routine preventative visit.

Is this common? I can continue getting the losartan from my friend, but I would have to go to a visit to get the labwork paid for. I really don't want to go to his office, because I know too many people there. I would prefer to keep my medical information private, with a provider that is not known to me.

[AnnaN5]

It can be a hard situation. I see the office's point of view. I recently made the switch to family practice so am seeing a lot of patient's new to our office. Many of them are "well controlled" on their HTN, lipid, etc medications and want a year's worth of refills at their initial visit because they are about to run out. I order lab work and give them refills but then of course they never go get the labs done. I personally don't feel considerable continuously prescribing meds when I don't have any labs to review. That provider may have been burned by the same type of situation in the past.

[scottaprn]

They aren't charging you for a follow up of your physical. They are charging you for obtaining and interpreting your lab results and medical decision making involved in your second visit. Problems found on your lab work most likely weren't addressed on your initial visit.

Why should the physician not be paid for that?

[babyNP., APRN]

Depending on what state you live, you can go ahead and private pay for the labs yourself. There are quite a few websites that let you pay for it and then you usually take it to a Quest Diagnostic center. A doctor "signs" the order, but it's done en-masse instantly, so you don't need to see a provider to request the lab or to see the results. I've done that for myself a few times when I didn't want to deal with going to a clinic. Labs aren't too expensive and you can use your HSA/FSA funds for it.

[blondenurse12, MSN, NP]

Well, I can see things from both perspectives. I work in retail health and we can do some managing of chronic disease by refilling existing prescriptions and doing labwork (HgA1c and lipid profiles). Many patients who run out of meds basically didn't bother to see their PCP. They bounce around, trying to keep getting refills. I understand PCP offices want to establish some continuity of care and don't want to just prescribe things and never see you again.

As a patient, it can be frustrating because sometimes it can take six to eight weeks to get in for a yearly physical/new patient exam and then four more weeks to get a follow up appointment so by then, you're out of meds. However, if all the labs are normal, then it seems like there is no reason that you need to come back in to discuss this.

I suppose my advice would be to find an office that is a patient centered medical home that has an online component. For instance, my doctor orders my labs and it pulls straight into my online portal. I can view my labs whenever I like. So for instance, you go for a yearly physical, they order labs, you get the labs, they are normal, then you view the normal labs and send an email to request the re-order of your losartan.

[automotiveRN67]

The results of the labwork is always yours, even if you choose to skip the follow up. I can see if labwork was abnormal, and something needed to be changed, this would require medical decision-making, and therefore a fee for the follow up.

If labwork is normal, however, I don't see a reason to hold a patient ransom for a follow-up fee. In my mind, annual physical pays pretty well. If labwork comes back normal, see you in a year.

It seems like price-gouging to me. And the funny thing is, it breaks down continuity of care, and probably delays treatment in many cases. Patient will skip on to the next PCP, without having adequate management.

[anh06005, MSN, APRN, NP]

I usually discuss things over the phone unless there are several things to discuss or something serious that may need some discussion (crazy a1c, questionable mammo, etc). If it's just general med adjustments I'll give you a call lol.

Maybe if you explain your situation and that you are a competent provider also the doctor will make an exception. I feel like my doctor would (if I went in often....).

[automotiveRN67]

I have a solution, I just wanted to know what was common in internal medicine these days.

It isn't a hardship for me to pay for an extra visit, like it may be for some patients. But in my mind, an annual visit should cover continuing the same single medication after revieweing normal labwork, and allow for one year follow up.

I was just wanting to poll others, to see if this was a trend in internal medicine.

[scottaprn]

It isn't a hardship for me to pay for an extra visit, like it may be for some patients. But in my mind, an annual visit should cover continuing the same single medication after revieweing normal labwork, and allow for one year follow up.

What qualifies as your free exam (Of course the cost is built into your premium) and what in your mind should qualify are two different things.

This isn't Preventive Care: Medical treatment for specific health conditions, on-going care, lab or other tests necessary to manage or treat a medical issue or health condition are considered diagnostic care or treatment, not preventive care.

Obamacare Preventive Care