I wrote last week about a real-world curbside consult from my IT colleague, Jimmy the Greek. As promised, here is the second installment of Dr. Jayne’s Journal Club, where we will continue with our patient case presentation.
When we last left Jimmy, he had been referred from the physiatrist to an orthopedic surgeon. I didn’t go into detail about insurance or how much this has been costing him, but since it’s a new year, I’m betting he’s facing a new (and most likely daunting) deductible. When I was a CMIO at Big Health System, we always saw a dip in business during the first month of the year, but things picked up in February as people met their deductibles. I don’t have access to that kind of performance data any more, but I wonder what those curves look like given the expansion of high deductible plans.
At the end of my last piece, I had just made an appointment to review my MRI results with Dr. Professional himself. I arrived at the appointed time (15 minutes prior to the appointed time, actually) and after I explained why I was there, I received a terse “ID and insurance card” along with the outstretched hand of the front desk attendant (who, for reasons unbeknownst to this author, was the only one in the office wearing scrubs.)
After a considerable wait, I was shown to an exam room, where I met a physical terrorist … err, therapist. She took down the same history I had provided the doctor in previous visits, so either my records weren’t updated or she didn’t bother to read them. Finally, the doc comes in and pulls me out into the hall, where he has my MRI results pulled up. Yep, in the hallway, where anyone walking by can take a look. So much for HIPAA.
Dr. Professional explains that he sees some osteoarthritis and he wants me to consult with an orthopedic surgeon to see about laparoscopic surgery. I’m given a referral and sent on my merry way.
A friend of mine is an orthopedic surgical nurse at Big Hospital System, so I asked her about the guy who might shove soda straws into my hip joint (Yes, I watched the YouTube video. Yes, I now know I should not have done that.) She asks around and comes back with a consensus from the docs she asked: “He’s competent.” Not exactly a ringing endorsement, but I’m planning on a second opinion anyway, so I set up an appointment to see Dr. Competent.
Being a savvy healthcare consumer, I obtained Dr. Competent’s new patient forms from his practice website, printed them, and filled them out ahead of time. Confidential to all of you CMIOs and practice managers out there – fillable PDFs are a thing now, and if you don’t have them available for patients, you should. If you can’t figure out how to do it, I’ll do it for you – contact me through Dr. Jayne. I promise my rates are as reasonable as the amount of time I spend in your waiting rooms.
Upon arrival at Dr. Competent’s MegaOrthoMart Practice, I handed in my homework, forked over my ID and insurance card, and was promptly handed two additional forms to fill out, which requested much of the same information that I had provided on the phone when making the appointment and on the forms I filled out ahead of time. Then I got to wait until a registrar became available, and she more or less walked through the forms and asked me if each line item was correct. It’s now 35 minutes past my 8 a.m. appointment time and I’m still stuck in the lobby.
Someone finally comes to get me and the first thing they want to do is take x-rays. Remember the last installment? I’ve had x-rays and an MRI. Despite the fact that I brought the imagery with me, MegaOrtho insisted on doing their own because they “can’t be certain of the technique used to obtain [my] existing films.” I tend to believe the real reason they wanted to take more x-rays was more along the lines of, “This way we can bill your insurance company for more services.” When I get my explanation of benefits, I’m sure I’ll see an office visit from Dr. Competent, a facility fee from MegaOrtho, and imaging fees from MegaRadiology. At least MegaOrtho is independent and not part of Big Hospital System or they would be after their piece of the pie, too.
At 9:15 AM (a full 75 minutes past my appointment time), I finally get to see Dr. Competent in all of his frat-boy glory. Without introducing himself (what is it with doctors just assuming you know who they are?), he proceeds to explain what’s wrong, explains that surgery is an option, but a cortisone shot and physical would be a better first step. I’m all set to get the cortisone done, but he explains that he doesn’t do that for Dr. Professional’s patients. So now I get to make another appointment with him for an ultrasound-guided cortisone injection.
At this rate, I’m going to need to take a second job just to fund my co-pay habit (see “fillable PDF” offer above). The cynical part of me can’t help thinking that this is just a scheme to extract as much money from me and my poor, innocent insurance company as possible. I don’t begrudge anyone the ability to make a living, but this just seems excessive. (For those of you keeping track at home, we’re up to three appointments with Dr. Professional now.)
The one bright spot in this adventure has been the staff at the physical therapy place. Everyone there is friendly and efficient. Here’s to a speedy recovery and success in physical therapy. If I have to have the hip scoped it, it’s a longer recovery than I’d like, so keep those patient information forms coming my way; I’ll apparently have lots of time on my hands to create fillable PDFs.
Looking at this entire saga through my CMIO lens, the element of the story that strikes me most is the fact that we’ve spent billions of dollars trying to make healthcare better and we still haven’t solved the basic problems that patients face. Let’s look at customer service. In some situations, customer services has gotten worse as front desk staff are under increased pressure to ensure collections. Staff members are also encouraged to maximize throughput even if it doesn’t make sense and patients are filling out duplicative information. We haven’t mastered basic technology such as fillable online forms and practices are often reluctant to fully leverage patient portals, especially to collect information on new patients.
We still have clinicians who are too busy to read (or don’t trust) the history in front of them, so they ask redundant questions. We haven’t spent money transforming our office spaces to increase patient privacy or comfort and still show images in the hallway. Despite the advent of provider ratings and online reviews, patients still have limited information to judge a physician’s competency. We’ve also pushed providers and health organizations to the edge of financial viability, leading to increased reliance on provider-based billing and facility fees to get as much money out of the system as possible.
Despite the ability to exchange data or having images on CD in front of us, we repeat testing because we don’t trust our peers or are too pressed for time to look at the films before we decide whether the outside radiology group’s technique was adequate. Or maybe we’re just after the money. We have handshake professional agreements where a consultant doesn’t provide a service to a patient when he could, and instead sends the patient for another visit to the referring provider (and another co-pay and another day off work). I hope our patient’s cortisone injection and physical therapy does the trick because I would hate to see him panhandling for contract PDF work outside the next medical staff meeting.
Unfortunately, the continued push for more use of EHR technology and more metrics and more data points isn’t going to change human behavior. It seems like it’s getting harder to find organizations willing to spend money on the so-called “soft skills” or on truly transforming healthcare. They’re too busy trying to figure out how not to be penalized or worrying about when their vendor is going to release the next version of Certified EHR Technology.
What’s the answer to making healthcare something we can be proud of? Email me.
Email Dr. Jayne.