Curbside Consult with Dr. Jayne 12/11/23

I’ve been doing some locum tenens work in a traditional family medicine practice. I can attest that the negative feelings that primary care physicians have towards performing uncompensated work are real.

I was brought in to provide coverage for a physician who is on family leave. I was impressed that the practice would go through the work effort to bring in a locum tenens physician. Many practices just expect the rest of the staff in the practice to absorb the excess work, which often causes resentment when there are partners who take more frequent family leave and others who feel that physicians should “power through.”

That was an interesting dynamic that played out during my interview process with the practice. The partners who were making comments about why they didn’t think my assistance was needed were generally older and/or male, and those who voiced support for having a locum were generally younger and/or female. However, there were some exceptions to the rule.

I hadn’t been told what kind of family leave the physician I’d be filling in for was taking, but was surprised at how willing some of the partners were to share another physician’s private information. One told me, “I worked every day during MY chemo, so I’m not sure why she thinks she needs to be out for her chemo.” On the surface, it’s an unprofessional comment, but it also clued me in to the potential for burnout in this practice since burnout is often associated with lack of empathy.

Another physician told me how glad he was that there would be locum coverage because he was tired of covering his partners because “so many of them have been popping out babies.” He mentioned that he didn’t ever feel the need to take paternity leave and his kids turned out OK. It was good to be clued in about the fact that I would be taking a trip to the cultural 1970s in this wayback machine of a practice, but I agreed to take the job anyway.

Although I have deep experience with the EHR the practice uses, I went through all the onboarding steps, which was good because I got to know the practice’s in-house trainers and super-users well. Fortunately, the practice’s use of technology didn’t mirror their attitudes, and I was impressed by how much delegation and automation they had in place for patients who had medical needs in between their office visits – things like refills, questions about lab tests, etc. Most of those were handled by appropriately trained staff members using standing orders and clinical protocols, which were also built into the EHR for efficiency. I’d give them an A-minus grade for overall efficiency compared to other practices I’ve seen, so I was surprised to hear some of the physicians complaining bitterly about their inboxes.

After getting my feet under me for a bit, I was able to explore what was really going on with patient messages since I was getting a lot of them. It’s been a while since I’ve been in an ambulatory practice during the typical open enrollment period for health insurance, and it turns out that questions about insurance plans, medications, coverage, and the like were making up a high volume of patient questions. Not only were employed patients sending in questions, but plenty of retirees had questions, too, thanks to some recent marketing campaigns on TV that tout the benefits of Medicare Advantage plans. It sounded like many patients were facing dramatic premium hikes and were trying to figure out how to get what they needed in the most economical way possible, but like most patients in the US, they lacked the context to be able to formulate the right questions.

For example, one question was, “Is Cigna better than BCBS for my medicines?” Since this question wasn’t addressed by any of the existing triage protocols, it came to the physician to address. No physician, care coordinator, or health navigator can answer the question with the facts provided. What kind of Cigna or Blue Cross Blue Shield plan are we talking about, HMO, PPO, or something else? Is it a commercial Cigna plan, or one that’s for a self-insured employer that just uses the Cigna network? Are there carve-outs for religious exemptions for employers in this predominantly red state? Is the patient using mail order or retail coverage? Are they stable on their medications or do they have new conditions that are being optimized? Patients were asking their primary care physicians because they felt they had nowhere else to turn to try to figure out what to do for their families.

One of my colleagues mentioned that he saw an article “where someone fed the plan data into AI and then asked it to make comparisons,” but noted that it would be nearly impossible unless you had all the plan details for the various options. Another mentioned that he just tells patients to call their employers and see if they have someone who can help. One noted that he had done that in the past, but found that employers were telling patients to call the office since they didn’t have any idea what the patient’s medicines were to determine the level of coverage. All of this together just goes to illustrate some of the key failings of our healthcare non-system in the US.

The idea that patients should be seen as consumers is part of the problem. Historically, consumer education in the US relies around people being able to make comparisons around price, looking at products with features that they generally understand. It’s one thing to compare the per-ounce price of two brands of pasta sauce, but things get more complicated when you’re trying to compare major appliances like washers. It’s another thing entirely to compare interest rates and mortgage terms to figure out which loan is the best option for a new home purchase. Looking at even more complex consumer comparisons, such as the purchase of an electric versus gas-powered vehicle, it’s different for people to assess because that decision also injects somewhat less-tangible values and feelings about renewable energy, tax policy, and more.

Now, take it to the highest level. Trying to perform comparisons of health insurance coverage is more like graduate-level consumer education. Given the levels of health literacy in the US, it’s no wonder that patients often have little understanding of their coverage.

Recent efforts to make price transparency data available to the public aren’t helpful for the majority of patients. A lot of healthcare is unplanned, and those are the costs that typically push people over the edge. Data from 2022 shows that nearly 40% of people in the US couldn’t cover an unexpected $400 expense. When someone’s child gets bounced off the trampoline and breaks their arm, parents aren’t going to head into the house and price-shop the internet to find the best deals on x-rays and orthopedic consultations. If they’re savvy, they’ll call the number on the back of their insurance card, make sure the emergency visit is authorized, and go to the facility they’re directed to. But a good number of patients are just going to hop in the car and go to the nearest hospital.

At the other end of the spectrum, when you’re diagnosed with a life-changing condition like cancer, what patient has any idea of all the healthcare charges they’re about to get hit with? How are you supposed to shop that around?

For patients with longstanding primary care relationships  — which are becoming fewer in this transactional healthcare landscape that is riddled with third parties trying to pick off the easiest and most profitable patients — these questions roll downhill to the primary care physicians, who are barely better equipped to answer them than the patients themselves. I took the issue to the office manager, who hadn’t previously been made aware of the volume of inquiries the practice was receiving. I’m glad I brought it up because it turns out that the practice’s affiliated health system has volunteers within their patient advocacy department who are tasked with helping answer those questions.

The practice was able to quickly throw together a protocol, including the creation of some quick phrases in the EHR to respond to patient questions and get them headed in the right direction. For those skeptical about having a locum in the practice, I guess I provided a little value-add that day. Now that open enrollment is largely over, those new workflows will be dormant for a while, but it’s nice to know that they’ll be ready for next year. 

As I thought through the whole process, it made me think about the use of AI to make this easier. All of the data needed to make true meaty comparisons lives in the EHR and its corresponding practice management or revenue cycle management system. You have all the medication data, including patient compliance and stability of the treatment regimen. You know what pharmacy the patient uses. You have the data on the different insurance plans such as contracts that at least give an idea about allowable charges and expected adjustments. You also have the data on other physicians the patient sees and their past history.

Certainly some smart people could figure out a way to pull that together along with the data from the insurance plans’ Summary Plan Descriptions, the employer and employee costs, and cost data from the local market. I’d pay money for something like that to help me make the hard decisions and I’m betting I’m not the only one.

What’s the solution to the chaotic problem of choosing your insurance coverage for the year? Is AI the answer? Leave a comment or email me.

Email Dr. Jayne.