I don’t think it’s necessarily greed.
Your doctor may be on a system where they are responsible for doing work for you (e.g. refilling your prescriptions, doing whatever insurance paperwork it takes to make your prescriptions go through, keeping track of when you need to get certain tests, etc) without receiving any compensation except when you come in for office visits. One patient like this isn’t so bad. Half your caseload like this means potentially hours of unpaid labor every day. Even if an individual doctor is willing to do this, high-level decision-makers like clinics and hospitals will realize this is a bad deal, make policies to avoid it, and pressure individual doctors to conform to the policies.
Also, your doctor remains very legally liable for anything bad that happens to you while you’re technically under their care, even if you never see them. If you’re very confused and injecting your insulin into your toenails every day, and then you get hyperglycemic, and your doctor never catches this because you never come into the office, you could sue them. So first of all, that means they’re carrying a legal risk for a patient they’re not getting any money from. And second of all, at the trial, your lawyer will ask “How often did you see so-and-so?” and the doctor will say “I haven’t seen them in years, I just kept refilling their prescription without asking any questions because they sent me an email saying I should”. And then they will lose, because being seen every three months is standard of care. Again, even if an individual doctor is overly altruistic and willing to accept this risk, high-level savvier entities like clinics and hospitals will institute and enforce policies against it. The clinic I work at automatically closes your chart and sends you a letter saying you are no longer our patient if you haven't seen us in X months (I can't remember what X is off the top of my head). This sounds harsh, but if we didn't do it, then if you ever got sick after having seen us even once, it would legally be our fault. Every lawyer in the world agrees you should do this, it's not some particular doctor being a jerk.
Also, a lot of people really do need scheduled appointments. You would be shocked how many people get much worse, are on death’s door, and I only see them when their scheduled three-monthly appointment rolls around, and I ask them “Why didn’t you come in earlier?!” and they just say something like they didn’t want to bother me, or didn’t realize it was so bad, or some other excuse I can’t possibly fathom (to be fair, many of these people are depressed or psychotic). This real medical necessity meshes with (more cynically provides a fig leaf for, but it's not a fake fig leaf) the financial and legal necessity.
I’m not trying to justify what your doctor did to you. If it were me, I would have refilled your insulin, then sent you a message saying in the future I needed to see you every three months. But I’ve seen patients try to get out of this. They’ll wait until the last possible moment, then send an email saying “I am out of my life-saving medication, you must refill now!” If I send a message saying we should have an appointment on the books before I fill it, they’ll pretend they didn’t see that and just resend “I need my life-saving medication now!” If my receptionist tries to call, they’ll hang up. At some point I start feeling like I’m being held hostage. I really only have one patient who is definitely doing this, but it’s enough that I can understand why some doctors don’t want to have to have this fight and institute a stricter “no refill until appointment is on the books” policy.
I do think there are problems with the system, but they’re more like:
- A legal system that keeps all doctors perpetually afraid of malpractice if they’re not doing this (but what is the alternative?)
- An insurance system that doesn’t let doctors get money except through appointments. If the doctor just charged you a flat fee per year for being their patient, that would remove the financial aspect of the problem. Some concierge doctors do this, but insurances don’t work that way (but insurances are pretty savvy, are they afraid doctors would cheat?)
- The whole idea that you can’t access life-saving medication until an official gives you permission (but what would be the effects of making potentially dangerous medications freely available?)
Epistemic Status: Overheard in New York
I am walking and talking with my friend, a Type I Diabetic, when he receives a phone call from his doctor’s office.
As a Type I Diabetic, my friend needs insulin. The effects of not having insulin are very bad, and include death.
He has run out of refills on his prescription, and will run out of insulin on Saturday. He called about a week ago to attempt to remedy this situation and get refills.
That’s for background. This isn’t about the order of magnitude higher my friend’s copay is in America, compared to the entire retail price in Canada.
This is about my friend’s attempt to get legal permission to continue buying life-saving medication for a lifelong condition with no known cure.
Because for some reason, in America you need legal permission to buy it, and you need to renew that periodically, despite there being chance of the need for said life-saving medicine going away.
I overheard the phone call from my friend’s end. The rest is filled in based on a combination of talking to him after, and extrapolation. He has reviewed this for accuracy.
The nurse tells my friend he needs to go see his doctor, because it has been seven months, and the doctor feels he should see his doctor every three.
My friend replies that he agrees he should see his doctor, and he has made an appointment in a few weeks when he has the time to do that.
The nurse says that he can’t get his prescription refilled until he sees the doctor.
My friend explains that he does not have the time to drop what he is doing and see the doctor the next day. That he is happy to see the doctor in a few weeks. But that until then, he requires insulin to live.
The nurse says that he can’t get his prescription refilled until he sees the doctor. That if he wants it earlier he can find another doctor.
My friend explains again that he does not have the time to see any doctor the next day, nor can one find a doctor on one day’s notice in reasonable fashion. And that he has already made an appointment, and needs insulin to live. And would like to speak with the doctor.
The nurse refuses to get the prescription filled. The nurse does not offer to let him speak to the doctor, and says that he can either wait, make an appointment for the next day, or find a new doctor.
My friend points out that without insulin, he will die. He asks if the nurse wants him to die. Or what the nurse suggests he do instead, rather than die.
This seems not to get through to the nurse, because my friend asks these questions several times. The nurse does not offer to refill the prescription, or let my friend talk to the doctor.
My friend says that if the doctor does not give him access to life saving medicine and instead leaves him to die, he will post about it on social media.
The nurse now decides, for the first time in the conversation, that my friend should perhaps talk to his doctor.
The doctor calls a few minutes later. The doctor is quite upset about this threat to post on social media about being denied access to purchase life saving medicine.
The doctor accuses my friend of having a gun to his head. My friend points out this is a rather interesting choice of metaphor. One could say that the doctor has a gun to his head, in the form of denying him access to life saving medicine. And that the two do not seem remotely comparable.
This seemed right to me, as I had used exactly the words ‘gun to your head’ when discussing the situation with my friend between the two phone calls.
I was not referring to the possibility of posts appearing on social media.
The doctor goes over details of my friend’s care. He wants my friend to come in.
My friend agrees. Points out he already made an appointment. That he needs insulin to live.
The doctor asks, what if your sugars are high?
My friend points out that if this were the case, he would still need insulin to live.
The doctor keeps asking my friend to come see him. My friend keeps pointing out he has already agreed to do this.
The doctor continues to admonish my friend for his blameworthy behavior of only doing all the things he’d been asked seven months ago to do, of only seeing several other specialists for tests, rather than also seeing this doctor every three months as a good obedient patient properly concerned for his own health would have done.
My friend points out that regardless of all that, he would still need insulin to live.
The doctor then admonishes my friend for his terribly blameworthy behavior of not being aware he had run out of refills. Clearly, my friend should have tracked that. My friend points out that he doesn’t keep the prescription boxes, he keeps the vials. That few patients know, no matter what they in theory ‘should’ know, how many refills they have left on a reliable basis. And that he had realized all this a week ago and called his doctor, but was only now hearing that the refill wasn’t going to be forthcoming. Also, to paraphrase a bit, he asked the doctor: Why the hell is it going to run out at all, anyway? Are we expecting a cure real soon now? This need for insulin to live isn’t going to go away.
Having properly pointed out all the ways my friend was bad and should feel bad, the doctor now claims that the nurse was never told that the doctor wasn’t going to refill the prescription without my friend coming in first.
My friend points out that the nurse did in fact say exactly those words. That the prescription would not be refilled without a visit first.
What the doctor then claimed he said to the nurse was rather that the doctor did not want to refill the prescription. That the doctor would prefer that my friend come in.
This is standard implicit command deniability. Pure gaslighting. It’s the same as when a mafia boss says it would be great if a certain someone wasn’t seen round these parts some time soon. Or when the CEO remarks that people seem to be using too many vacation days. The nurse’s job depends on enforcing the implied order given by the doctor.
The doctor asks why my friend is being so unreasonable. My friend points out that he started with an entirely and unquestionably reasonable position of agreeing to come in at his next available time in exchange for continued access to life changing medicine.
That he’d only changed to what the doctor was characterizing as the unreasonable position of ‘if you deny me life saving medicine I might tell people that you did that’ when it was clear that until he threatened that, he was going to be denied life saving medicine.
If anything, the original position seems to me like it points out that the system has given someone the power to threaten to withhold life saving medicine, that they agree the person needs, in order to coerce the behavior they want from the other person. Which seems bad. But hey.
After a number of minutes of such admonishments, my friend having been sufficiently interrogated and admonished for his dastardly non-submissive, non-compliant role, and his unwillingness to drop everything in his life on a dime for no reason, the doctor offered to renew the prescription for long enough to make it to the appointment. Thus allowing my friend, for the low low co-pay price of ten times what it costs in Canada, to legally purchase the life-saving medicine he will need periodically for the rest of his life.
In some ways this was the good scenario. In the end, access to life saving medicine was in fact renewed. And this was what happened when my friend had, he insists, an unusually conscientious doctor, who is using his powers of coercion, via the threat of withholding lifesaving medicine, entirely to ensure the health of his patients, and who was in the office and capable of responding promptly.
Ladies and gentleman, the American medical system.