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Curbside Consult with Dr. Jayne 1/23/17

January 23, 2017 Dr. Jayne 11 Comments

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.

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Currently there are "11 comments" on this Article:

  1. Good points all around. I want to echo the dissatisfying aspect of clinicians NOT introducing themselves. It is a patient satisfier and something our parents taught us. And it’s easy to do.

    • In fairness to the clinician, they don’t want to seem to be rude when introducing themselves to someone they’ve already seen (but can’t possibly remember). I’d recommend they go with a “It’s great to see you” and wear an identifiable and easy to read name tag.

  2. Is it just me, or does it seem like the more things change the more they stay the same in healthcare – at least from a customer service standpoint? It would be interesting to see a flow chart/visualization of all the appointments this patient has had to schedule with each provider and the co-pays associated with each. Then I’d like to see an overlay of how many of those appointments/co-pays could have been avoided with more coordinated care.

  3. Reminds me of a recent visit to a Foot & Ankle clinic for a followup for a broken toe. The doctor had canceled all her appointments on the day I was originally scheduled (not a complaint, life happens, emergencies happen, that’s the world), so all those patients were rescheduled for the following two days. When I got there, the waiting room was full, so one person had to stand — in a Foot & Ankle clinic. We’re all there because our feet and ankles aren’t working! The doctor was so backed up she was running 50 minutes behind, two people left, and one man got his toe run over (again — Foot & Ankle clinic!) because the already-jammed-full waiting room was arranged so badly that a man in a wheelchair didn’t have a straight path to the door and had to do a tricky little turn at the end, resulting in the toe-running-over incident. The doctor and her resident were both pleasant enough, and repeatedly congratulated me on my minimal swelling, and all in all I got out of there unscathed but I’m (relatively) young and in very good health so I can absorb the inconvenience; I worried about the elderly and more vulnerable patients in the waiting room and what their day was shaping up to be.

    Like the letter-writer and his PDF consulting hustle, I was tempted to offer my services to run the clinic for the day just to get them out from under it all. Reasonable consulting rate, too, the only extra I ask for is free coffee.

  4. At the end of the day, the clinics rates are fixed by their customers who pay via insurance. Why should the clinic change if improving results in almost no change to their compensation? This is why socialism, communism , etc don’t really work and capitalism with its market functions does. Capitalism has an efficient pricing function that works vis-à-vis the free market. With no real pricing function, guess what? The have no incentive to change. Make that clinic self pay only and I guarantee they would either they find a bigger waiting room or they’d have less patients.

  5. At what point does the patient simply say: No?

    Personal anecdote. I took a family member to the Doc over a fall, and the Doc asked for images, plus a referral to a specialist a week later. We had to go to a private imaging clinic, pay for them, get a prescription filled. It made for a very long day.

    The week later we see the specialist. He immediately orders a new set of images! I challenged him but he claimed that he “wanted to see the changes” in a week.

    As patients and citizens we get lectured about responsible use of the healthcare system. This got a little too close to gratuitous use of medical resources for my liking.

    We caved and got the new images. But it left me wondering. Should we have put our foot down and said No? Use the expensive and inconvenient set of images we got for you a week ago. Or perhaps, only get the latter imaging done and skip the first imaging appointment.

    Like I said it felt gratuitous.

  6. I’ve saved money recently by going into “insurance incognito” mode when dealing with a ortho issue. We found out last year that our Orthopedic Doctor (“Dr. BestOrtho”), who our family loves due to all the things he and his partners do right from a customer service perspective, offers a flat fee of $300 if a patient doesn’t have them file insurance directly. (If you are the parent of three boys – trust me, you need a favorite orthopedic surgeon!)

    For a flat $300, I received a pleasant and unhurried office visit with Dr. BestOrtho, where I didn’t wait too long (even though it is a busy office), got an X-Ray (w/ image copy), received diagnosis of “Frozen Shoulder “, yes, apparently that is a real thing, got a Cortisone shot, and an honest recommendation of: “We should just wait this out for awhile. You just need a big dose of patience (since your right arm no longer works) and extra large bottle of Ibuprofen. Surgery is rarely needed or even helpful FS typically resolves on it’s own. Eventually.”

    Oh yes – and the followup visit coming up in a few weeks is also included. (And if something has been broken, that would include casting services if it could be done in office).

    Best healthcare deal I’ve experienced in years!

    • “Self pay discount”, my friend. Back in my days of billing support I found a lot of practices had something similar in place; if you could pay cash at the time of service, they’d cut you a deal. It was worth it to them to take a small hit on the revenue to guarantee cash in their bank account and not have to pay out the operating expenses associated with filing the claim, getting denied, filing it again, getting it denied for some other reason, etc.

      • How did you make the discount happen? Just ask the front desk person while you are there, call ahead before booking, or try to convince the doc during the visit? It makes perfect sense all around that cash customers should pay less, but I always wondered if practices are prepared to offer the discount on request. It would be helpful, of course, to know what insurance would have paid and to get the discount off that amount instead of list price, but that won’t happen.

        • I was working on the software side of the house so I don’t know how that conversation went. This was pre ACA so the number of uninsured was substantially higher, and I suspect it was part of the conversation when the appointment was booked or during check-in. Patient has no insurance? Mention “self pay discount” if they pay at the time of service. I’m not sure how that conversation would work today, but it might be worth asking when booking an appointment. Thisi s reaching way back into the memory bank, but to my recollection the ones that offered it offered a rate that hovered around the median of what they would get paid across their payer mix.

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