Physician Referral Form For Health Study: Fill & Download for Free

The global answer is lack of a free market, but that takes many forms. I'll go into some of the major forms.1. The Flexner Report prior to WWI and especially Abraham Flexner's follow-on muckraking book caused Congress to shut down half the medical schools in the US (including all those of alternative practices) and to support the inherently costly gatekeeper model of medicine (physician as sole accessway to treatment and medications).Shutting down the schools and increasing their stringency greatly limited the supply of physicians. Here's a quick illustration of the costliness of the gatekeeper model. My oldest at 15 accompanied an author to Guatemala. She came down with tourista and gave him a dollar to go to the corner farmacia to buy opiates. Within a couple of hours, problem solved. That inexpensive option gets jail time in the US. One must have a doctor's signature to mend legally.2. Third-party payers. The more insurance companies have to pay, the more they get to charge for premiums. They lack incentive to keep costs down. They also have an incentive to cover as much as possible, including non-medical problems.Example: Kaiser did a study and broke its membership into six segments, three profitable and three quite unprofitable. Profitable were people like me who avoid going to doctors, people who faithfully go for checkups and follow their regimen, and chronics--people with diabetes, cancer, heart disease and so on who follow their regimen. Unprofitable were chronics who did not follow their regimen and who live abusive lifestyles (smoking, alcoholism, sedentary, drugs), acutes--people, usually immigrants, so fearful of the system that they do not present until a problem is acute, and hypochondriacs--people who use any sniffle as an excuse to see the doctor. You will notice that the common factor making the unprofitable segments unprofitable is behavioral rather than medical. Yet we all get to subsidize it. Subsidized activities seldom subside.3. Absence of self-medication--partly because of the gatekeeper model, partly because of paucity of ready, reliable information and partly because of bogeyman stories from doctors and the medical press, most people want to go to the doctor for problems they could easily take care of themselves. Example: I got a large cyst on my neck that a doctor charged me $450 to remove (almost $2000 in today's money). A month later while visiting my parents it came back. Not knowing what else to do, I went to see my old pediatrician. He told me to go home and put a hot "washrag" on it and don't come back again--I was grown up now--and charged me nothing. I put a hot compress on it. In half an hour it opened and drained and has never come back.4. Lack of disintermediation. Disintermediation is the opposite of gatekeeperism. If A has to go to B to get to C and you remove B, the process is usually swifter and cheaper. It's well known in medicine that RNs could handle the bulk of items handled by doctors but that remains a no-no, a legal no-no. But here's a better example. Benign paroxysmal positional vertigo affects lots of older people but a simple treatment was developed in the last couple of decades. An ENT might perform the head manipulation every other day, but a GPs office might see only one or two cases a month. They do not bother to learn the procedure, which is not effective if not done precisely. I helped an ENT who'd developed a cap with clinometers on it to make it difficult to do the procedure imprecisely so that a nurse practitioner in a GP's office could offer it. He thought it would make the procedure an $85 walk-in affair rather than the week-or-two ordeal waiting for a referral appointment that charged $2000 affair. But he was solicitous that other ENTs not be able to source the product to him as he knew they would resent the threat to their income. There was no legal restriction in this case--just peer pressure-- but a great deal of medical practice has legal constraints to disintermediation. No free market.5. We can estimate from the Pareto principle that twenty percent of medical procedures offer eighty percent of the benefit. Studies support this. Trauma care, vaccinations and antibiotics are of unquestioned benefit. Roughly half of medical procedures offer on average no bang for the buck (we do heal on our own most often). And in some ten percent of cases, we are better off not to see a doctor, especially when the presenting symptoms are vague. For example, my brother went to some sixty doctors over fifteen years and was rebuffed with offers of referrals to psychiatrists, told to give up--he would not get the drugs he was after, told it was all in his head and so on. He was suicidal. Finally, he saw an immigrant doctor from Africa who said, "The symptoms you are describing are those of Lyme Disease but given how many physicians you've seen, someone is bound to have tested you for that." Sure enough, he had gone all that time undiagnosed with a disease that is a priority in Continuing Medical Education.Despite such discrepancy in benefit to patients, the AMA heralds a "gold standard" treatment for every condition and presents the front that all of medicine is equally efficacious. This is part of the reason Obamacare will fail to control costs.Medicine is a sector badly in need of free-market reforms.Charles Tips's answer to What are the problems with Free Markets?

This question asks that we answer with 2-dimensional thinking. This issue will never be solved by 2D thinking. What happens if we look at it with 3D thinking?What do we all want? We want good health. We want it all the time and available to us competently and affordably as intervention is needed, rich and poor alike. Ideally, we will be able to choose a physician relationship based on trust and know that that care provider will not be limited to fifteen minutes twice a year of well-care.When the first clinic opens up near me that I can join for a nominal monthly fee, say $100 a month or maybe even as low as $60… perhaps a family plan for $200 or so a month, I will join. How does that work? In return for that retainer, I would expect to be on a wellness regimen, seeing the doctor as necessary to put me on a track to good health, including nutrition and weight-loss counseling and programs, fitness and exercise too, and mental optimization.Some of these programs I might have to pay extra for, if I choose them, and there might not be a physician involved in those aspects, but certainly someone knowledgeable. If the clinic offered chiropractic and acupuncture as options, that would be a big plus for me because, despite my strong skepticism in both cases, they have proven to have unique value for certain issues. All programs would feed into a file that says whether I am on track and what the best way is to get me there.That is likely to involve nutrition advice or disease-avoidance based on my genetic profile. Should I be overweight or sedentary, perhaps I pay a higher fee for the risk I represent.But what if, God forbid, something terrible happens to me? Do I have to pay out of pocket? No, the clinic would insure all of its patients against calamitous health issues as part of what your fees go for.Does that not sound better, ideal even?I wrote a history of a medical school a decade back. The chief of the surgical department told me a story about taking a group of med students to an Hispanic free clinic where there was a woman with a six-week-old that was not prospering. He put his students to the task of figuring out what was wrong, which involved making a makeshift scale, sniffing soiled diapers, abdominal palpitation and so on.The students swiftly concluded there was no infection; the baby must be on the wrong formula. One of the clinic staff was sent out to her car to fetch the formula—sure enough, she’d been given formula for 12-months-and-up. A change of formula, and the follow-up with her showed the baby doing just fine. Then he added, “Do you know what that workup would have cost in-hospital? At least $2000.”Based on that story, I asked several physicians I interviewed to indulge me in a hypothetical. Physicians, who must always focus like a laser on the here-and-now, hate what-if scenarios. But I got three to go along. “Would it be possible to operate clinics that were not just free but that paid people to come for regular checkups on a break-even basis or even turning a profit?”All three eventually agreed it would be possible… theoretically, but very complicated. As one put it, “Do you realize how many laws you would have to change?”“Do you realize how many laws you would have to change?” traces back to the first government foray into the practice of medicine, the Flexner Report of 1910 and associated congressional hearings. Given that this was the Progressive Era, the thrust was to make certain that medicine remained a profession for Anglo-Saxon Protestant males. It shut down all medical schools not operating on the Prussian Koch school of medicine.* (Osteopathic medicine’s five schools survived the onslaught and became home to women, Jews and Catholics who wished to pursue medicine in the US. That included some blacks, though two all-black medical schools were allowed to survive, with two others shut down, on the thinking that would supply sufficient medical care to black communities.)The hearings also opened the door to the inherently costly “gatekeeper” model of medicine in which patient access to medicines and specialty services comes solely via their primary physician. They also put the American Medical Association firmly in charge, making it the nation’s first large-scale lobbying association (and the origin of most of those laws that need changing).I was out for a run one gorgeous day on the San Francisco Peninsula more than three decades ago when an athletically built red-headed gentleman fell in beside me. The discussion quickly turned to diet, and I laughed him off and told him I had never reduced my intake of butter, bacon, eggs and cream. Rather, I watched my intake of sweeter carbs and eliminated sugar from my diet.He told me I was an idiot asking for a heart attack. “There’s nothing wrong with sugar,” he blurted, “it’s just quick energy.” I thought this awfully presumptuous and asked him how heart attacks were unheard of among cultures that ate lots of animal fats or in Mediterranean diets and what about diabetes?The man started getting red in the face, his voice rising as he announced, “I happen to be a cardiologist. When I say you should watch your fat intake, you should listen.” His hands were now balled up in fists, so I simply veered left and went my own way without another word.For years, on the rare occasions I told that story, listeners would often chime in with him, “He’s right.” Now we all know he was wrong, dead wrong, as in people died because of his willingness to dispense pure ignorance.The Koch school of microbial medicine produced heroic advances, the wonder of the world. It has also produced antibiotic resistant “bugs.” It has caused a lot of other areas of medicine to be ignored to the point that, while a plague of resistant pathogens now stands as a distinct menace, our big problems are no longer medical.Thanks to my wife’s employment, I was privy more than two decades back to a Kaiser Permanente study of profitability by member cohort. It showed that all of medical care was profitable.Guys like me who saw a doctor once a decade were quite profitable (they still didn’t approve of us… our thinking might catch on)Those who came to scheduled check-ups and followed doctors orders were the A students, and profitableThose with cancer, diabetes, lung diseases, heart disease, who followed their regimens… profitableWho wasn’t profitable?Those with sedentary to abusive lifestyles—incipient chronics—who failed to follow doctors’ orders (or, as in the case of my cardiologist running buddy, followed doctors’ ill-informed advice)Wary members, usually immigrants new to the system, who hold off presenting until the condition has become acuteA surprisingly large cohort of hypochondriacs, people who see the doctor multiple unnecessary times each year on flimsy pretextsAll of the cost overruns owed to behavioral problems! Foremost among the staggering cost of American medicine is the fact our present system has no incentive (except for Health Maintenance Organizations like Kaiser) to curb bad behaviors. Most of the government programs being pushed are not for medical care; they are insisting that all of us subsidize bad behavior.A local ENT, or ear, nose and throat doctor, a decade back requested my help with an announcement of being the recipient of a prestigious grant to develop a process that would take a common inner-ear problem from being addressed by referral to a specialist, a $2000 procedure, and allow it to be handled by a nurse practitioner with a quick stop at a clinic for $80.The reason he wanted my help was to craft it in a way that played up the prestigious aspect without giving away any hint that he was about to take an appreciable amount of cash out of the practices of his peers.When I was interviewing lots of physicians, they all, one way and another, were thankful for being in a cutting-edge profession. But then would come a revelation like, “When Tagamet came out, I lost half my gastric surgeries. I had a very tough year.” “When colonoscopy came on the scene, I lost all of my exploratory bowel surgeries. I almost went out of business.” “When the Beta-Blockers came out…” and so on.Those were all boons for us patients, but doctors are not aligned with our best interests. Having to revamp their practices and learn new skills is a hardship.My next younger brother visited more than sixty physicians over a fifteen-year period from his late twenties to his mid forties seeking to find out the source of his ceaseless nerve pain. Several primary-care docs offered to refer him to a psychiatrist. Several more scolded him for seeking pain killers and ordered him out of their offices. Most simply said there was nothing they could do for him.Finally he chanced upon a physician trained in Nigeria who had come here for a medical-research PhD. After reciting his symptoms, the man said, “You are describing the classic symptoms of Lyme disease, but surely, as many physicians as you say you have seen, you’ve been tested for that.”“No, I’ve never even heard of it.”Lyme disease has been a top emphasis of continuing medical education year-after-year for decades, since before he contracted it. The earlier the diagnosis, the more successful the treatment. My brother didn’t get a diagnosis until it was well into secondary stage and his quality of life was quite compromised. More than five dozen American primary-care docs failed my late brother utterly and completely.The winds of change need desperately to blow through the medical profession.The American College of Lifestyle Medicine is the new kid in town. They represent just one of the zephyrs that need to blow. We’ve reached the point, foretold by the Kaiser study mentioned above, where lifestyle issues, correctable by a change in lifestyle, account for some eighty percent of medical costs.But with government involvement and a lobbyist organization devoted to damping the winds of change as much as possible, those helpful breezes cannot blow. When I view proposals like the Patient Protection and Affordable Care Act, with my entrepreneurial mindset I see one thing only—a last-ditch effort to lock in the practice of medicine in this country in its present sorry state, an effort to keep subsidizing lower-quality care at unaffordable prices.What is necessary is a system that aligns costs and interests. A system thatputs the cost for poor lifestyle choices on those responsible, forcing changereduces the tremendous overhead of insurance-driven paymentsincentivizes physicians to innovate in the best interest of patientsdemands care providers stay up-to-date on the broad scope of health issues, not just medical onesrequires physicians to tackle rather than boot problem caseshave physicians pay for the insurance so that better patient outcomes produce lower operating costsis flexible in dealing with medical innovation and staying up on accurate informationprovides low-cost ways of profitably initiating lifestyle improvementsIf you look at the system I outlined at the outset, you will see that it has the potential to achieve all of these desirable realignments significantly reducing costs all around, substantially broadening the provision of care and making sure that our care providers have a financial stake in providing truly cutting-edge care to us so that we stay healthy and their balance sheet does too.* Well before the Flexner report, Sam Hahneman, the founder of homeopathic medicine, took to referring to the form of medicine that survived the Flexner shakeout as “allopathic” medicine, meaning “other than the problem.” It was an indictment of the tendency of western medicine to engage (expensively) in symptom management rather than address underlying issues, keeping illness a “cash cow.” The name stuck.

We are in the US and we adopted a child from Korea. Our process had many, many steps in it it took 16 months from initial paperwork until the child was placed with us, and then another 9 months for the adoption to be finalized.Most of the steps are designed to protect the child by making sure the adoptive parents have truly thought through their decision, are healthy, financially stable, have no history of criminal activity, drugs or child abuse, live in a place suitable for raising a child, etc.To prove my point, here is my exhaustive list of to-do items from our adoption in 2005-2008. Each of these items took time and many steps required extra fees.Fill in & file agency's preliminary application, including photos of us and the houseWrite medical statement, elaborating on treatment for any medical conditionsLine up four non-relative referencesOne copy of tax returns from past three yearsPay $200 fee to adoption agencyNotarize agency's adoption services agreementFill in the "Home Study Part 1 Paperwork" . Each spouse does the following:Fill in "Personal Data" form with 67 essay questions1 photocopy birth certificateComplete Authorization of Release of Information - Employer VerificationCriminal Record StatementLiveScan fingerprint form (for State of California: criminal and child abuse index)Schedule & attend LiveScan fingerprinting appointmentsMedical Exam, including HIV and TB tests, with Medical Report filled out by doctorComplete detailed Financial Statement1 photocopy marriage licensePhoto of baby's future roomPrint Map & directions to homeCopy all, keep for recordsEach of 4 non-relative references return 3-page, 10-essay questionnaires directly to agencyHome Study Part 2:Receive & pay invoice for home studySchedule social worker visitsSocial worker visit #1 (both husband and wife)Acceptable Medical Conditions Form filedSocial worker visit #2 (wife only)Social worker visit #3 (husband only)Sign up & take module 1 & 2 of agency's parenting classReceive 2 completed, certified, notarized copies of Home Study from social workerAgency sends Home Study to Korea (HSTK)Sign up & take modules 3 & 4 of agency parenting classI-600A filed with US-CIS (Advanced Processing of Orphan Petition for Visa) (4/6/2006), including the I600A form, Copy of certified home study, copies of each spouse's birth certificate, photocopy of marriage license, copy of most recent federal tax return, proof of medical insurance, $800 fee, cover letter.FBI FingerprintingReceive I-171H (Approval of I-600A) from US-CISReceive Referral to a Child, which is a packet of information with the child's history, photos, medical records, etc.Medical evaluation of Referral by Oakland Children's HospitalFile Referral Acceptance Paperwork to agency, along with huge fee to adoption agency.File 3 Placement Agreements with agency - all notarizedhusband: 4 Statements of Adoption (for child's Korean passport) - all notarized3 Travel Option forms1 Foreign Travel Release - notarizedhusband: 2 Affidavit re INS Vaccination Requirementshusband: two I-864 Affidavit of Support for Immigration filed with US-CISwife: two I-864A Contract between Sponsor and Household Member filed with US-CISSend US-CIS: copy of entire last year tax return, last year's W2 & 1099s, photocopies of both our birth certificates (again), copies of both our paystubs, Photocopy of marriage license (again)Receive child's "legals" from Korea (in English & Korean)I-600 visa petition form filed w/ US-CIS. Includes copies of legals, I-600, I-171F, child report & photos, copy of most recent 1040 tax form, copy of I-864, copy of I-864A, letter to American Embassy in Seould with visa cable instructionsMeanwhile, the Korean adoption agency worked away:Our application was translated into KoreanKorean agency applied for Emigration Permit ("EP") with Korean Ministry of Health and WelfareMinistry approves Emigration PermitAgency gets I-171 (I-600 approval) cable from US Embassy in SeoulVisa physical for baby, including Hepatitis B & HIV testsSubmit application for baby's IR-4 VisaResubmit our I-600 visa petition after US-CIS screws up and loses the first oneThen, we went go the "Travel" call and flew to Korea.Plan trip & travel to KoreaIn-Korea pre-flight medical examGo to US Embassy in Seoul to process Class-B Waiver (acceptance of medical condition)Get the final Visa paperworkTake custody of child!Once home, there was more paperwork:Receive Placement Confirmation Notice from AgencyReceive baby's Green Card in mailGet social security number under baby's Korean Name as permanent resident4 post-placement visits from social worker, where I also had to create 5 page "progress reports" with answers to questions and photos.File US Physician's Examination Report with AgencyOur adoption agency finishes the "post placement phase" and gives us approval to officially adopt the child in American court.File Adoption Finalization Paperwork in our county in California: Forms ADOPT-200, ADOPT-210, ADOPT-215, and ADOPT-230Receive "Consent to Adoption" from agencyAdoption Finalization hearing in County CourtSend agency/Korea copy of child's adoption decree (child is no longer considered a Korean citizen)Secure proof of US citizenship for child: Complete & file N-600 with US-CIS, pay feeReceive Certificate of CitizenshipFile passport applicationReceive passportApply to SSA to get status changed from resident alien to citizen, SS# name changed (passport is proof)Start the process all over again for kid #2!