For Wordless Wednesday.
Why, you say, do you need to SEE your doctor for a referral? It’s so stupid!
2. Scarce resources.
3. Your primary care may be able to handle it.
4. The specialist only wants to see people that they can help.
5. You may think that you and Dr. Google have it figured out, but Dr. Google sucks.
6. For physical and occupational therapy, it has to do with caution and malpractice insurance.
Let’s go through them backwards.
6. People call for a referral to physical therapy. I say I need to see them. No, I can’t make a diagnosis through the phone. Arm hurts is rather vague. The person says their insurance does not need a referral. But then the physical therapist wants one: why? Well, my malpractice outranks the physical therapists, so to speak. If the therapist sees you without your doctor examining you and something happens… yes, things have happened.
5. Dr. Google. You’ve read extensively and you know exactly what is going on and you just need the referral. No, you have not gone to medical school or residency. Every quack who can say anything even faintly convincing now has a website. Dr. Google sucks. There are very very rare exceptions to that…
4. The gastroenterologist does not want to see your bladder problem. The neurosurgeons hate seeing the people that will not benefit from back surgery, but they have to because the back pain patient doesn’t believe me, so the patient has to hear it from the surgeon. The patient thinks I am “gate keeping” them from the specialist. I’m not.
3. Primary care learns to handle a lot of things. One frequent referral is a postnasal drip, to the Ear Nose and Throat specialist. I recommend trying an acid blocker first. The person doesn’t believe me. “I don’t have heartburn.” I sigh, and do the referral. $450.00 later, the ENT has put the scope through their nose and put them on an acid blocker.
2. Scarce resources: We had 8 neurologists on the Olympic Peninsula for about 450,000 people. We are down to two. I called one for a complex stroke-that-wasn’t and had to do a series of MRI/MRA studies looking for specific things. It was a vertebral arterial bleed. Rare. I called the neurologist back and he said, “Send them to the other one. I am swamped.” He is in the larger population area and two others quit. The rule is sickest is seen first…
1. Triage. What is wrong, what are we worrying about and how sick is this person? If they are really sick I will call the specialist to ask for recommendations, or which test to do, or see if they need to be seen within a short time. I am not going to interrupt the specialist unless I think it’s really necessary! That would burn through my carefully built credit with them! And I have had a person come in for a new patient visit for a “lung problem”. I call the specialist, get him seen and he has a heart bypass….
0. And I am a specialist too. I am a Family Practice physician, board certified and board eligible, three year residency. The internist, the pediatrician, we are all specialists and all special.
Navigating health care in the United States is challenging and challenged. Currently the 800+ insurance companies, each with multiple “products”, the 500+ electronic medical records that don’t talk to each other, the increasing volume of information and the decreasing number of physicians make getting care very challenging. Here are some steps to help you navigate.
1. Get your records and keep copies.
Get the disc of any radiology studies: MRI, xray, CT scan, echocardiogram. Keep them. Hand carry to your visit with the specialist. Yes, I know your doctor said they’d be sent and I know the specialist’s office said they’d get them, but I have two friends so far this week in two days who traveled 2 hours or more to a specialist who DID NOT HAVE THE STUDIES. Do NOT give your only copy to the specialist. Demand two. Either get them on different days or just pay for the second disc.
A clinic closed in our area a year ago. It was in three counties, 3400+ patients. The physician owner was not paying the bills, including the electronic medical record. We couldn’t get records, the emr company wouldn’t release them. Gone. Thirteen people called to be new patients with me the day the clinic closed and we took five new patients a week for 6 months. You need a copy of your records.
2. In the specialist’s office or ER, do NOT give your records to the receptionist.
Hand them to the physician only. Hand them copies, you keep copies. “When will you be getting back to me?” That is, if it’s two hundred pages of complicated records, when does the physician think they can read (some) of them? The real truth is that WE CANNOT READ ALL OF THE OLD RECORDS. We don’t have time. We have to sleep. We read what we can and there are MOUNTAINS of old records that we haven’t read. I have files of old records and I pull them for visits so we can look up specific things. I have asked patients to go through and find specific things: find me the MRI report of your back.
Because what is really happening in many offices is that the information is being scanned but not read. Truly. I think this is dangerous. I had a patient who had five specialists and me. I was sending updates to his rheumatologist, with letters, asking questions and not getting a word back. Finally the patient went for the two hour trip to see the specialist, who called me: “I had not read any of your notes! I didn’t know what was happening!” I saw RED. Oh, so my letters and the ER notes and the other specialist notes that I faxed to you MYSELF about a very sick, very complicated medicine WERE NOT READ? I wanted to scream at her, but I didn’t. I just said, “We really need your help and I have been trying to keep you informed.” Through gritted teeth. Then later I kick and hit my heavy bag. And at that point the specialist was finally helpful. It still makes me furious just to think about it, so I have to work on forgiveness once again.
In my office, if a physician (me) has not read it, it has not been scanned. There will NOT be surprises in the scanned chart. The unread old records are filed alphabetically and when I have a time turner, I will have time to read them all, right? And then in a visit, the person asks if I got their mammogram report. I have to LOOK, because I sign off on about a billion different pieces of paper a day and I really don’t remember the names of all the people who had normal mammograms. I don’t try to remember that: I know who has an abnormal one, because I am worrying about them.
3. Make a record trail that you can quote.
When you call the physicians office, get the name of each person you speak to. Write it down. Have them spell it. Ask how soon you will be called back. Ask what you should do if you do not get a call back. (That being said, every physician has to prioritize the calls. It’s sickest first, not first come first served. If your call really is an emergency, then you should be in an ambulance, not calling your doctor.)Our local mental health was in such disarray, understaffed, underfunded, that my instructions to non-suicidal patients were: “Call every day, be polite, and call until they make you an appointment. Do not wait for the call back. Call daily, they just don’t have enough staff.”
If you fax them the missing notes, keep a copy of the fax proof. Call after your fax the missing records. Ask if they received them and then write down the name of the person you spoke to, date and time. I put a computer message in the chart for 99% of the phone calls I have with patients. I may miss 1% because I get interrupted or a really sick patient arrives or another phone call or whatever. Ask when the physician or his assistant will be calling you back about the records or better yet, make an appointment: “He did not have the records, so I would like an appointment as soon as possible now that he has them.” This forces your physician to look at the old records, because the patient is coming in. I do not read old records before a new patient shows up. I used to, but then people no show for a one hour new patient visit and I feel used, abused and grumpy. So I don’t touch the old records until you show up. After two one hour new patient no shows we tell the person they need to find another physician. Two strikes on the new patient visit and they are out.
If a person is really really sick, family or friends should be there. Ask questions. Who is each person who comes in the room? Do they have the clinic notes? Don’t assume they do, I am not on our hospital’s EMR because it costs 2 million dollars. The inpatient hospitalist doctors almost never call for my notes. I fax my notes anyhow and call them, but the information gap is BIG ENOUGH TO DRIVE THE MOON THROUGH. Really. I am sorry to burst the electronic medical record bubble, but we have 500ish different EMRs in the US right now and they do not talk to each other, so every patient arrives accompanied by 2 years of paper records (or more), 200 pages or more. I joke that they need a bigger doctor because the paper is too heavy for my 130 pounds. And many many times, the hospital medicine list is wrong. It is old. It’s out of date. The person is sick as hell in the emergency room and they don’t remember that their lisinopril dose was changed three weeks ago. One person in the room with the sick person and keep a notebook and write down what the physicians and nurses say, time, date. Then if they start contradicting each other, ASK.
5. In clinic
Give your doctor the whole list right away: my foot hurts, my chest is really bad when I try to run up the stairs, there’s this thing on my arm and is my cholesterol too high? Don’t discuss one thing in detail and then bring up the next. I have long visits, but I can’t do justice to that list in one visit and I have to prioritize. This requires negotiation: the chest pain has my attention. You may be focused on your foot, but the number one killer is heart, so your doctor will worry about your heart first.
If the doctor asks you to bring in all your pills, bring them all in. There are three different types of metoprolol and five strengths of each. Do you know the type and strength of every drug? I want to see your vitamin bottles because vitamin B1 can cause neuropathy from too high doses and yes, they can sell high doses. I want to see the supplements: why are you taking bovine thymus/testicle pills? By the way, if the doctor actually looks at the supplements, keep that doctor. Most don’t.
6. Be careful out there. Good luck.
A patient of mine saw a cardiologist recently.
His previous cardiologist has retired. The patient had a cardiac bypass in the past, he has a stent, he has known coronary heart disease and he’s in the young half of my practice. That is, under 60.
He had not seen a cardiologist for 2-3 years because he had a work injury, worked with Labor and Industries, the case was closed, he couldn’t go back to work, he found a lawyer. He lost his regular health insurance along with the job, so couldn’t see the cardiologist.
The L & I case is reopened. A physiatrist recommended specific treatment that was not done, and that allowed the case to reopen.
The specific treatment center then notes that he has heart disease and that he needs clearance from a cardiologist. I set him up with a new cardiologist.
“How was the visit?” I ask.
He shrugs. “The staff was nice.”
“I have the note.”
“The cardiologist spent under ten minutes with me. It was clear that she was rushed. She did not seem very interested. It was difficult to get my questions answered.”
“Her note is six pages.”
He snorts. “Great that she could get a six page note out of that visit.”
“Do you want a copy?”
He is cleared for the specific treatment.
I have no doubt that the cardiologist spent more than 6-8 minutes on his visit and his note. But not in the room. Other people are entering the information filled out in the waiting room, medicines, allergies, past medical history, family history. Hopefully the cardiologist is reading my note and letter. But the problem is, doctors aren’t doing it in the room. So the impression left with the patient is that we spend 6-8 minutes on their visit, we are late, we are rushed. Doctors are looking at data. They are not listening to patients.
Medical Economics, a journal that arrives without me asking for it, says over and over that we need more physician “extenders”, that we need to have people doing the data entry, people doing the patient teaching, more people and machines….No. They are wrong. We need LESS barriers between us and the patients, not MORE. We need more time with patients. Every single extender we add burns physicians out more, because the salary has to be paid AND more patients seen faster to do that AND we are still ultimately responsible for knowing and reading and absorbing every single piece of information that is placed in that patient’s chart. An extender is NOT an extension of my brain and an extender is another person I have to communicate with and train.
Just. Say. No. to the managers who pile MORE barriers between the physician and the patient. NO.
It just makes me so mad that he lost his health insurance BECAUSE he got injured at work and so then his heart disease goes untreated as well… can’t afford medicines…if he then has a heart attack while uninsured we lifeflight him to Seattle, it costs a fortune, he loses his house and property and then is on medicaid and may end up on permanent disability, and what are the chances he returns to work? The US medical corporate money grubbing is insane. Single payer, medicare for all, make the US great again.
The letter P and my theme is happy things. But what comes to mind are these P words: prior authorization, pharmaceutical, payer.
Prior authorizations are NOT a happy thing. The latest twist from insurance companies, three different ones in the last week, is that they are requiring prior authorization for old inexpensive medicines. I ordered a muscle relaxant for night time only on Thursday last week for a person with a flare of back pain. Friday I was dismayed to see that the insurance company was requiring a prior authorization. I have to prioritize the order of urgency of all the work: I did not have time. I called the patient who had paid cash for it. The insurance company wins. They didn’t have to pay for a covered medicine because they made it difficult to get. They keep the patient’s money.
Prior authorizations are on the rise very rapidly. With over 800 insurance companies, each with a different website, each with multiple insurance “products”, no one can keep up with it. It is a shell game, the ball under the cup, three cups moving, but the ball is the money and it’s already palmed by the insurance companies. I predict that this will continue to get worse. We do need a single payer system for the simple reason that physicians will not be able to hire enough staff to learn and navigate 800 different websites. I do most prior authorizations on the phone in the room with the patient: the other day we spent 35 minutes on the phone only to have the insurance company say that we had called the wrong number. Call another one. Not the one on the insurance card. We could complain to the state insurance commissioner, but my patient is afraid of losing their insurance. Time’s up. The prior authorization is not obtained, and we are five minutes into the next patient’s visit. People are finding that the medicine they have taken for 20 years suddenly requires prior authorization.
And remember: prior authorization is your insurance company making rules and extra paperwork for your physician. It is advertised as a way to save money, but it costs YOU money. Back in 2009, the estimate was that physicians in the US had to spend 90,000$ per year EACH on employees to do prior authorizations by computer or phone. And YOUR insurance dollars go to the employees at the insurance company refusing medicines and dreaming up new medicines to refuse. They change the contract. Every year and during the year. The law is now that 80 cents of each dollar must go to healthcare, not profit, but those computer and phone employees are counted as healthcare. Do we really think that is healthcare?
Take CT scans. Medicare does NOT require prior authorization. But most insurance companies do. Think about that. Is age the difference? CT scans increase cancer risk over time so physicians don’t order them by reflex.
And for pharmaceuticals, insurance companies often have an on line formulary. But it is different for every insurance “product” in individual companies. A patient and I were trying to sort out a less expensive medicine on a website and we were having difficulty figuring out which insurance she had. Multiple abbreviations and color coding and we could spend the entire clinic visit just figuring it out. Is that what medicine is in the United States? You can say that someone else in the office could do it, but the more employees your physician hires, the less time the physician will spend with you, because he or she has to pay all of those people.
If there was one set of rules, one website, I would learn it. Medicare for all, single payer, when will the United States people wake up and tell congress: if you want our vote, make it so.
But wait, where are the happy things? I am so happy that I still am in business in my small clinic, p for patients and patience and prayer and single payer, we will have medicare for all in my lifetime. Whether I am still a practicing physician in the US at that time is uncertain. If I can’t afford my own health insurance, my clinic will close. Wouldn’t that be ironic?