Continuity of Care or a Culture of Kickbacks?

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.

Barbie Dream Body

 When you were a kid did you ever want to look like Barbie?  No?  Me neither…her breasts were too big and her waist too small.  I always figured she would break in half in real life, or at least have chronic back pain.

Blondie Bennett though, has always dreamed of becoming a real life Barbie doll.  She says that she was obsessed with Barbie as a kid and has modeled her life after the doll.

photo credit: <a href="http://www.flickr.com/photos/dollobserver/5499591092/">The Doll Observer</a> via <a href="http://photopin.com">photopin</a> <a href="http://creativecommons.org/licenses/by-nc-nd/2.0/">cc</a>

Now 38, she has had five breast enhancement surgeries and at this point makes Dolly Parton look “natural”.  She also has regular Botox injections and lip fillers to make her appear plastic and doll like.  Believing that “natural is boring,” she has gone to extremes to make herself into a living doll.

The most extreme of her actions is to participate in hypnotherapy sessions multiple times a week.  The goal of this hypnotherapy is to lower her IQ.  Her ultimate desire is not only to resemble Barbie in looks, but also to become brainless like the doll as well.  To hear Blondie in her own words, please watch this video.

In my humble opinion, it appears that this desire to become Barbie even to the point of brainlessness masks a deep psychological pain in this woman.  To purposefully work to forget your life and become ignorant of the world seems to me a red flag to deeper issues. 

However, we aren’t here to judge or fix this woman.  I chose to write about her story for two reasons: 1, I found it fascinating and 2, I think it is an interesting way to highlight an important issue in our country.  The current trend in laws and policies makes us increasingly financially responsible for and beholden to one another.

Take the healthcare law for instance.  With health insurance being subsidized by tax payers, we have a financial interest in our fellow citizens staying healthy.  Right now Blondie’s rent is paid by a “special guy” and some of her procedures funded by other gentlemen in her life.  I presume that one day, as she ages, these gravy trains will cease to run.  Where then will her money come from?  What if she suffers back problems from the weight of her super enhanced bosom?  What if her treatments to become brainless work so well that she is unable to enter the workforce or even care for herself because of her forgetfulness?  Since she chose to put herself in that position, should American tax payers foot the bill for her future care?

If the answer is yes, doesn’t that give us a vested interest in her behavior now?  We see this idea play out in campaigns against: smoking, drinking in excess, eating junk food, not exercising, using recreational drugs, etc.  I am not saying that we should encourage these behaviors by any means, but since we are now financially tied together through healthcare, whether or not people stop the high risk behavior has a direct effect on the wallet of every tax payer.

Blondie Bennett may have a contingency plan for her future and continue to live a self-sufficient life.  However, her eccentric life choices are an interesting case study for how involved we should be in the choices of others when the future cost of those choices could fall on our shoulders.  Whether or not you agree with the changing healthcare system it will inevitably lead to new discussions and decisions regarding healthcare rationing as it relates to risky health behaviors. 

Mulling over interesting and quirky stories like this one, could give us good practice for the deeper and more complicated questions we are sure to face in the future.

Take a Breath

The country has been gripped with interest watching the case of Sarah Murnaghan.  Sarah is a 10 year old Cystic Fibrosis patient who was in desperate need of a lung transplant.  The current transplant waiting list rules state that children under the age of 12 can receive lungs from an adult donor only if those lungs are not needed for an adult or adolescent in the same geographical area.

On the surface this may sound malicious and unjust, but let’s dig deeper.  In order for a child, under the age of 12, to receive adult lungs they must be re-sized for the smaller chest cavity of the child.  Current research says that this re-sizing process can make the lungs less stable and the transplant less successful than adolescent or adult transplants.

Being a logical thinker these types of media frenzy stories drive me batty.  An uneducated public is led by a manipulative or possibly, equally uneducated media to “react” on emotion rather than truly think about the issue.  In a moment the country was abuzz about the “unfair” transplant allocation rules and how we need to change them RIGHT NOW!

I am not saying that these rules don’t need to be updated; I am certainly no authority on lung allocation or transplantation.  My knowledge in this area is limited to information that came up in my recent Google search.  We may very well need to change the process, but let’s take our time, use logic, and consult the experts.

Certainly, Sarah’s story is heart wrenching and no one wants to see a little girl’s life end.  Medical policy however, cannot be created based on preventing whichever outcome would make us the most sad.  UNOS, the United Network for Organ Sharing, has difficult, almost impossible decisions to make every day about who receives the organs they have available.  They have to make these decisions logically and free of emotion.  To be truly just, they need to give the organs to patients who will benefit from them the most, this includes considering which transplants will be the most successful.

After the nationwide outcry and a court order, Sarah’s name was given priority on the lung transplant list.  She received her transplant and her body almost immediately rejected the lungs.  Three days later Sarah received a second transplant; it is extremely rare to receive two transplants so close together.  This second surgery was approximately two weeks ago, and according to press releases from her parents Sarah is doing well.

We should certainly all be happy for Sarah and her family and pray for her continued recovery.  I have no issue at all with the Murnaghan’s fight for their daughter.  I understand what it means to have a family member with a terminal illness and the need to exhaust every resource within reach to save them.  Any avenue that brings a family peace or allows them to continue the fight is fine with me.

I am disappointed however with the reactive media and general public.  Organ allocation is a complex process and should be treated as such.  This means any proposed changes should be thoughtful, logical, and well supported with data.  Sarah’s story stirs emotions in us and we want to help her, but what about the other people on the transplant list?

Maybe there is a 15 year old honors student, or a 22 year old with aspirations for medical school, or a 25 year old mother of 2, or 40 year old father of 5.  We need to keep in mind that Sarah’s is the story we know, but not the only sad story on the lung transplant waiting list.  We trust UNOS with the decisions, because they have a commitment to making them logically, based on need and benefit rather than emotion.