I received the following comment in response to a post. Is this a taste of things to come as accountable care organizations take hold? Does this story raise doubts at all about President Obama's promise that patients would continue to have choice under the Patient Protection and Affordable Health Care Act? Did our legislators and Governor Romney envision this result when they enacted the Massachusetts health reform law? Or is this an isolated case related to one medical practice group?
I offer it for your reactions:
My PCP is in a large multi-specialty practice in MA. The practice absolutely insists that all referrals for sub-specialty care go to providers in their practice.
For the most part I have complied, sometimes reluctantly. I've seen ortho, derm, podiatry, gyn etc etc. I've given them plenty of business.
But now I want to go to a sub-specialty provider outside of their practice and definitely don't want to see their doctors for this particular part of my care. They have told me they will give me a referral for one visit for a "second opinion", but otherwise if I want to see that specialist outside their practice for ongoing care, I will need to get a new PCP outside of their practice who can refer me.
I told them I understand their business model is to encourage patients to stay in the group, but that I have a right to go whatever practice I want to and that my insurance will pay for. They responded that this is "managed care" and that if I want to stay with their group I need to use their providers only.
I have a lot of reactions to this. I'm angry I'm being made to jump through hoops with a resulting delay in my care. I feel my rights as a patient are being infringed upon for their business interest. AND, I'm offended that they are willing to lose me as a long-term patient for this short excursion to the outside world.
But besides that, here are my questions:
1) Is this really "managed care?" I thought that had to do with my insurance limiting where I can go and how many visits will be covered, not the policy of the medical practice.
2) Can they really do this? Do I have any legal rights that, if my doctor deems that sub-specialty care is medically necessary, that they need to give me a referral to the practice of my choice? I heard of pediatricians "firing" patients who don't vaccinate their kids, so is this in the same vein... if you don't play by our rules go play somewhere else?
I offer it for your reactions:
My PCP is in a large multi-specialty practice in MA. The practice absolutely insists that all referrals for sub-specialty care go to providers in their practice.
For the most part I have complied, sometimes reluctantly. I've seen ortho, derm, podiatry, gyn etc etc. I've given them plenty of business.
But now I want to go to a sub-specialty provider outside of their practice and definitely don't want to see their doctors for this particular part of my care. They have told me they will give me a referral for one visit for a "second opinion", but otherwise if I want to see that specialist outside their practice for ongoing care, I will need to get a new PCP outside of their practice who can refer me.
I told them I understand their business model is to encourage patients to stay in the group, but that I have a right to go whatever practice I want to and that my insurance will pay for. They responded that this is "managed care" and that if I want to stay with their group I need to use their providers only.
I have a lot of reactions to this. I'm angry I'm being made to jump through hoops with a resulting delay in my care. I feel my rights as a patient are being infringed upon for their business interest. AND, I'm offended that they are willing to lose me as a long-term patient for this short excursion to the outside world.
But besides that, here are my questions:
1) Is this really "managed care?" I thought that had to do with my insurance limiting where I can go and how many visits will be covered, not the policy of the medical practice.
2) Can they really do this? Do I have any legal rights that, if my doctor deems that sub-specialty care is medically necessary, that they need to give me a referral to the practice of my choice? I heard of pediatricians "firing" patients who don't vaccinate their kids, so is this in the same vein... if you don't play by our rules go play somewhere else?
I think the patient absolutely has a choice. He/she can stay in that practice or choose another.
ReplyDeleteTalk about a business not communicating its value proposition to a customer! What if the term "co-ordinated care" had been used instead of "managed care"? The patient clearly does not believe seeing their specialists yielded them any additional benefits ("I have complied, somewhat reluctantly") vs. the cost (choice). The practice needs to ask themselves if the issue is deeper than communications i.e. there really is no value prop to the patient to their multi-specialty practice and what opportunities are available to them now (e.g. IT advancements).
ReplyDeleteIt looks at first glance like this practice is trying to maximize revenue generation. However, I wonder if they are being paid on a fee for service or a capitated basis. Also, is utilization by PCP’s being tracked and is that a factor that figures into their bonus, if any? If compensation is fee for service, there should be no reason why the patient can’t go outside the group, provide her PCP with any results from tests ordered by the outside doctor along with his or her office notes and still have her care manage or coordinated by the group her PCP belongs to.
ReplyDeleteFrom the group management perspective, there should be a way to exclude utilization driven by doctors outside the group from the bonus determination process if the patient specifically requested a referral to an out of group provider.
It's inconceivable that someone who has earned a livelihood in the health care field for as long, and as lucratively, as Paul Levy could sincerely inquire whether "this story raise doubts at all about President Obama's promise that patients would continue to have choice under the Patient Protection and Affordable Health Care Act?"
ReplyDeleteOf course it doesn't. That's practically a non sequitur. The individual's confusion is pretty transparently a product of the subject medical practice's overreach/mismanagement.
Look up Occam's Razor, Paul, and learn how to use it.
Thanks for the suggestion, but I think you miss the point. The reference to the President, of course, is that his plan envisions ACOs that may also choose to act in this fashion and that his promise of patient choice therefore may not be fulfilled.
ReplyDeleteIs it possible that the payer is tracking referrals?
ReplyDeleteThe only thing I can think of is that the payer may have struck a deal with the practice to limit referrals when the care can be provide in-practice. The practice can probably provide the necessary care (according to the PCP) for a cost lower than what the payer expects to pay for the referral service.
Just a thought.
If we want to control costs, we can't let the patient choose everything they want.
My employer (an employer in the medical field) has changed its insurance offering to a preferred provider organization - employees electing to "chose" a more expensive plan can broaden their provider network however, providers are tiered and it will be more expensive to see an out of network provider.
ReplyDeleteIn theory this is a "cost containment" measure as well as continuity of care" vehicle (although I also believe it is a way of keeping medical re-inbursement dollars locked to a provider network). However, if the commenter feels he is being "strong armed" by his physician and receiving sub-standard care in areas of concern and the commenter is willing to pay the price for care outside his network then perhaps it is time that he change his physician and write letters of complaints to newspapers, insurance commissions, AG Offices and his medical insurance CEOs.
psgreader
Anon 11:30 AM –
ReplyDeleteWhile I agree that we probably can’t let patients have everything they might want, if the in practice specialist could provide the care at lower cost to the payer than the outside referral, the payer could offer the patient the option of reference pricing. That is, any difference in cost, at contract rates, would be paid by the patient and should make the payer indifferent to where she seeks care. The patient could then see her preferred specialist and pay somewhat more out of pocket for that option.
I would love to know if this practice is one of the 5 in MA (Atrius Health, BIDMC, MACIPA, Partners and Steward)chosen by the government to be in the Pioneer ACO model. If so, this is the wave of the future. If this were traditional fee-for-service with no risk contracting, this would not be happening.
ReplyDeleteI cannot comment on this story specifically, but the issue of choice is one that we are going to have to deal with eventually whether in ACO's or otherwise. Clearly having patients run all over town to each specialist of their choice (often chosen on the basis of poor evidence such as word of mouth) is inefficient and costly. However, it is equally clear that there are certain situations where the necessary inhouse expertise is absent. We all know of examples - my two are the young woman with severe mitral prolapse who was not offered the medically superior alternative of valve repair over replacement because her prominent staff-model care-provider (starts with a K) lacked the necessary inhouse surgical expertise; and the rare issue of bone and soft tissue sarcomas, which are often misdiagnosed and mistreated simply because of their rarity.
ReplyDeleteWe need to think through this issue carefully in a proactive manner, rather than wait till people die (our country's usual modus operandi). Perhaps 2nd opinions should be offered at in-network prices, or the patient can go to an outside specialist but pay at least part of the cost, or something. Choice should not be unfettered, but neither should it be absolutely forbidden.
nonlocal MD
What if a lone in-house specialist is a jerk? What if the physician provided poor quality care? What incentive is there for medicine to be patient-centered if within network business is a monopoly? And please don't bring up the bland and imprecise Press Ganey patient satisfaction measures in ACO contracts as any kind of nudge at all.
ReplyDeleteLogically, this moves toward much weaker incentives for public reporting of practice and individual performance. Choice, after all, will be irrelevant. For anyone with a complex or rare condition, this kind of management could be a death knell. Someone call the lawyers to be ready before this practice spreads.
What if the practice is breaking the law? Who is going to do the research, the leg work, and the follow through to get them to play nice? It's not going to happen. In fact, they are probably breaking several laws, but they are not accountable.
ReplyDelete