Recently, I did something I almost never do…I went to the
doctor for a physical. Yes, yes, I work
in the medical world and know how important it is to have regular checkups, but
unless/until it becomes necessary I steer clear of the doctor’s office. Unfortunately, this past April going to the
doctor became necessary…
You see, about a year ago I had to switch from my cushy PPO
plan to a less-than-satisfying HMO plan.
With this switch I now have to play the referral game. This wouldn’t be an issue except that my
glasses were disintegrating before my eyes.
Therefore, it was imperative that I brave the primary care physician’s
(PCP) office for an Ophthalmology referral.
To do this I needed to find a new PCP, so I picked Dr. Mary
Murphy on a recommendation. She saw me
as a new patient and I let her know about the referral I was seeking, she said
that since her computers were currently down I should call the office in a few
days for the referral, but it shouldn’t be a problem.
When I called the office a few days later, I was told that I
would be unable to go to my Beaumont doctor because of the “continuity of care”
policy at St. John Health System. The
conversation went something like this:
Referral specialist (RS) – “You must see a St. John’s
affiliated physician for continuity of care.
For instance if you were to be admitted to the hospital by this doctor,
you would not be admitted to a St. John’s facility and the medical records
would not be in our computer system.”
Me – “If I were to be admitted to the hospital directly from
my Ophthalmology follow up visit??? And just
how likely is that, do you think?
Besides, I could have the records sent to your office. I understand that you are concerned about your
continuity of care, but how about mine?
This physician has been treating my vision issues for the past 20
years. I have a complicated history with
my eyes and am not willing to switch specialists. Can Dr. Murphy make an exception in this case
for my continuity of care?”
RS – “Ma’am this is a policy of your Blue Care Network (BCN)
insurance.”
Me – “I don’t believe it is, I looked up my Ophthalmologist’s
office and it is within the BCN network.”
RS – “Ma’am I suggest you call your insurance company.”
Needless to say I hung up and promptly called BCN. They informed me their policy states that the
physician chooses where the patient will be referred and that BCN has no
involvement in this choice. So, I called
Dr. Murphy’s office back and clarified the BCN policy for them, since they seemed
confused, the response I got was unpleasant at best.
RS – “Ma’am I never said that it was BCN’s policy.”
Me – “Yes actually you did, you just told me to call them.”
RS – “Dr. Murphy will not give you that referral, we suggest
you find another PCP.”
I took their recommendation.
I usually try not to use this blog as a venting platform, but feel this
policy claiming “continuity of care” as a reason to trap patients in a certain
health system is patently bad for the health of the patient and something
should be said.
I think you should seek care from the best available
specialist for your disease or condition. I don’t live a life tied to one health system,
in my opinion it isn’t wise. Even though
a health system may be “best in the area” at one thing it won’t be best for
everything. And if you are sick, don’t
you want the best?
When Dad was sick we went to all three of the area ALS (Amyotrophic
Lateral Sclerosis or Lou Gehrig’s Disease) specialists, they were in three
separate health systems and we were able to maintain “continuity of care” for
his PCP just fine. In fact, going to the
different specialists allowed us to have a more complete view of Dad’s disease
and explore all treatment options.
So, is the quest of St. John’s Health System really for
“continuity of care” or is it ultimately a treasure hunt? For each patient kept in the system St.
John’s makes more money, so it seems to me they are more concerned with the
good of their pocket book than the good of their patients.
I single out St John and Dr. Murphy because I had this experience
with them, but I don’t think this is an isolated problem. Savvy patients beware, lest you become
trapped in a mediocre health care system when you have a serious illness.
oh yes - this has been a problem since at least 1999. We had to change from our PCP because of that very reason. At that point, I wanted to keep him as our primary, but since he was not in the system, we could go to him and pay out of pocket, but our insurance would not cover anything he prescribed, any referrals, and no hospitalizations if they became necessary. He was not happy back then with the way health care was getting centralized, hospitals and offices becoming governed by corporations, and would not allow his practice to go that way. Along with that, if you did go with BCN, which was an option for us, we would have been under that same situation you are now describing. So, thankfully we had 2 choices through my husband's work and we chose something other than BCN. Sadly, with the so-called AHCA, even having choices like we have had in the past are going away. I am not in favor of this type of centralized healthcare system, nor am I in favor of the mess that AHCA is. Sorry you are going through this, Theresa, and yes, I would get a different doctor. Interview them as much as they interview you. You might have to go to half a dozen before you find one who is not controlled by the system, by the insurance business that they are in bed with, and are truly interested only in the patient's best interest.
ReplyDeleteI'm sorry I didn't see this sooner, Theresa. Since we are now entering "open enrollment" season, I would recommend enrolling in a different medical plan (if you have the option) for 2015, or, if your only option is BCN and ophthalmology is your most significant medical concern, asking your ophthalmologist to recommend a good primary-care physician who will refer to him/her.
ReplyDeleteFor various reasons, I avoided primary care for 4-5 years. During the summer of 2013, I learned of an independent primary clinic (that is, not owned by a health system and, although the MDs have privileges at a health-system hospital, they do not exclusively refer to specialists within the same health system) and established care. My employer offers an HSA option, and because our medical expenses are moderate, the low(er) premium/high(er) deductible arrangement works for us in collaboration with our HSA fund. My only regret is that we cannot afford to contribute the IRS annual "family" maximum.
For 2014 (probably due to Obamacare) my employer moved from BCBS to a PPO with a more limited network. Fortunately, my two specialists were in the new network. Unfortunately, my new primary clinic was not. However, the primary clinic was one of the first in my region to offer an affordable retainer option, so I was able to keep them after all.
One benefit of retainer-compensated primary care is this: none of my visits are processed through medical coverage, and since my primary clinic doesn't use an EMR, details such as my weight and lab results are not recorded by my PPO or in some EMR-linked metadata-tracking database! Therefore, I have a little more medical data privacy than some people, at least for now. . .