Unintended Consequences: How HIEs force patients to quit their PCPs.

Last week, a patient who has seen me for more than 20 years called my office for an appointment. She signed up for one of the new HIE insurance plans but we are not a provider on that plan. She is a healthy woman, rarely needing my services and expected her new insurance to be her backup in case she became seriously ill. She was willing to pay cash to see me but this is unacceptable under Kentucky rules and considered “insurance fraud”. The reason given to her and our legal representative, by the Kentucky Healthcare Exchange (KYNECT), is that if a patient can afford to pay for a routine doctor visit then they shouldn’t need insurance. What? How does that follow? Since when does the ability to pay cash for a single visit mean that a devastating diagnosis and subsequent treatment would not wipe a patient out financially? One would assume lessoning that risk would be one purpose of the new insurance exchanges given that medical bills are the #1 cause of bankruptcies[1]! Insurance doesn’t need to be for routine visits. In fact, the entire basis of the DPC movement (Direct Patient Care) is to cut out the middleman of insurance from routine primary care visits.

Because I work for a healthcare system, my staff could not tell the patient what physicians and healthcare advocates “in the trenches” recommend, which is to hide your insurance status from your doctor’s office. There’s a great article entitled “Insured Patients Can Save Money by Pretending to be Uninsured” from the The Self Pay Patient website that explains how this works to many patients’ advantage.

I wonder, is this solely a Kentucky problem or is this an issue seen across the US? If anyone knows please leave a comment in the section below. In the meantime, if you are my patient and I don’t accept your new KYNECT insurance, well, I’m just sayin’…

1. LaMontagne, Christine. NerdWallet Health. http://www.nerdwallet.com/blog/health/2014/03/26/medical-bankruptcy/

Facebooktwittergoogle_plusredditpinterestlinkedinmailby feather

DPC, PHR, EMR, SoME and a couple other abbreviations

Watching the beginning of a training video for hospital administrators a couple of days ago made my head swim (and I can’t find the link on-line). It began with a gentleman walking his dog. Both he and his pet sustain minor injuries. They are sitting in the living room and his wife counsels her husband to see his doctor for an evaluation while she takes the dog to the vet. She calls the veterinarian office and is greeted with a real person who tells her to bring the dog right in. As she leaves her husband calls his doctors office and I’m already cringing at what I know will follow. Three minutes into the film (where it stops unless you want to buy), the gentleman is still on hold and has repeated his story to two different people. Meanwhile, the dog has already been seen by the veterinarian. This is getting better but it has been my personal experience and I hear frequent complaints from my patients. Fortunately they are less about my office than they used to be, so I think we are making progress. Rare the doctor’s office that has a real person answer the phone. It is discouraging to think that our pets get quicker, more empathetic care than we do.

Most of my Saturday was spent in the VA ER with a friend. It’s always interesting to be on the other side of the examining table. What I observed was the usual mix of caring and apparent disinterested staff. The individual I was with was in such pain he could not sit down. So for thirty minutes he stood, in obvious sight-line of three staff members. There was only one other patient in the waiting room at the time but it still took thirty minutes to get him processed and into the back. Once in the back, same scenario. No physician walked into the room for thirty minutes, it took another thirty to get him any relief. As I sat there being witness to this care, he said to me “Is this what a US single payer system would look like?” My thought was, “Gee, other countries do single payers well but can the US?” My French friends rave about their healthcare. My patients from Canada talk about how easy it is to get in to see their family doctor.

Lately I’m leaning more to changing how we reimburse primary care, rather than a radical change to a government-run payer system. The DPC system that David Chase discusses in Forbes makes sense to me.  As mentioned in previous posts, this is concierge medicine without the concierge price. For me it would be a win-win. I could see my patients for a reasonable monthly fee (which could be paid for by employers or patients) and in return they get more time with me and better preventive care. Add PHR (Personal Health Records), EMR (Electronic Medical Records) and social media to the equation and you have an opportunity for patients to become true partners in their care ( see the link to 6 things patients want from social media here).

Now if I can just convince my employer! 

Facebooktwittergoogle_plusredditpinterestlinkedinmailby feather

Reducing Fragmentation and Patient Care NOW not Next Year

I do not recommend doing this, but today I attempted to listen to two Webinars at the same time. One was also tweeting the discussion and the other had very detailed slides which made it easier to follow but as studies show, we are not really capable of that kind of multi-tasking. The topic of the first suggested it would discuss Primary Care and its future. However, what the expert proposed was a “How to” plan for bringing more customers into a healthcare system. This was boiled down to a recommendation that these system open small clinics, run by NPs, in competition with drug store and grocery store clinics of similar ilk in order to funnel patients into the listeners’ systems. The other Webinar was a discussion by three mobile health leaders (mHealth) on the future use of their products in the global mobile health arena (wow, that rhymed).
It’s is a good idea to know what is going on in the minds of healthcare system development teams and as I listened to the expert’s remarks I could not help but ponder on what, in my humble opinion, would build the kind of “team loyalty” that hospitals and other healthcare systems are dreaming of. What is it that patients want? I agree that they need healthcare access in their busy lives at more convenient times of the day than traditional physician offices offer. What my patients tell me (and what people tell me at cocktail parties) is that they would prefer access to their very own providers, those individuals who know them best. No insult intended to NPs because they are essential to the healthcare team, but they are physician extenders, not physician substitutes. What about developing systems that give patients greater access to their own providers? This would really engender loyalty to a healthcare system, especially one in which physicians are employees, more and more the norm these days. I believe mHealth can do that. What if you could access your physician after hours via Skype? Or text your doctor just for a quick conversation about whether you should seek immediate care or be seen the next day? Gee, what if the physician had access to their schedule and could book them on the spot?!? What I’m advocating here is a “concierge” type practice without the concierge price. Of course there would have to be some sort of reimbursement procedure to give already overworked primary care doctors the incentive to take care of patients in this way but wouldn’t that be a cheaper investment than opening the equivalent of “Little Clinics” everywhere?
Along with the cost, the second complaint I routinely hear from patients about their medical care is its fragmentation. From a patient and a primary care perspective, no one on the health care team is talking to each other. In fact, frequently the word “team” is a misnomer. Using tools like Doximity physicians can employ a HIPPA compliant platform to discuss cases and improve care. Of course the phone always works, but with the ability to ask questions and respond in a timely but convenient fashion, doctors and other providers like NPs, PTs, etc. can reduce the fragmentation patients feel from their healthcare team.
Of course I realize that ACOs (Accountable Care Organizations) are supposed to be developing this kind of care. But does the bureaucracy that surrounds these systems bother anyone else but me? Do we really have to wait for the lumbering movement of government sponsored programs in order to improve communication, fragmentation and access to care when the technology is already here today? 
Facebooktwittergoogle_plusredditpinterestlinkedinmailby feather