Monday, November 29, 2010

Is this normal?

This is a story about consumer choice using publicly available information. Unfortunately, it is also about the power of suggestion as used by an incumbent provider organization.

The friend who sent me this note is a research fellow at one of the Boston teaching hospitals, so I guess he is more likely than most to do the kind of research he summarizes. Most people would have taken the referral advice offered without question. If they ever did ask to see a different doctor, most would never get past the "need" for asking for "special permission."

Hi Paul,

I had a strange encounter, and I was wondering if you could tell me if this is normal.

A few months ago my primary care physician recommended I see dermatology for my eczema. His clinic recommended the names of two dermatologists within the same health care system. I looked up both dermatologist on and found that their patients had given them luke-warm reviews. (There were many reviews, so this wasn't a sampling problem). Also, I have been reading the medical literature about eczema, and knew there were a lot of recent advances, so I wanted somebody who had published and was familiar with the research.

I found another dermatologist, Dr. Caroline Kim. Her patients loved her (according to, she had published articles in dermatology research (from, and she trained at top institutions: Harvard Medical School and MGH. I made an appointment with her.

I called my PCP and asked for a referral. The receptionist told me Dr. Kim was "out of network" and they would have to ask my PCP for special permission. I thought this was odd because I had Blue Cross PPO insurance (not HMO), so as far as I knew, there was no "out of network".

A month later, my referral had not been sent. I called my PCP again, and asked for them to send it. After I gave her the name and phone number of the dermatologist, this was the conversation.

Receptionist: I am sorry, that is out of network. We will have to check with Dr. X.

Me: What does "out of network" mean? I thought I had PPO insurance.

Receptionist: You won't get the best care if you go out of network.

Me: Is this a [health care system] policy?

Receptionist: We might not know what medications you are prescribed if you go out of network. Your medical records might not get transferred back to our office.

Me: Is this a [heath care system] policy?

Receptionist: Yes.

A week later I had my referral.

It seems like this health care system is using an insurance term -- "out of network" -- to trick patients into going to specialists that work for the same company. Am I wrong?


Anonymous said...

Transpose PPO for ACO.

Do that, and your friend should be told, the reference price to see derm is "x" and your choice will cost you $125 OOP, etc. Our system wont pay additional.

Just a forecast, and probably a correct one. Will folks all have the same reaction?


Ed said...

From Facebook:

Why does this _not_ surprise me?

Anonymous said...

This also happened to my closest friend at a big, popular physician practice -- after a breast cancer diagnosis. She carefully chose an oncologist and a place for radiation treatment. When she made her choices clear to her primary care physician, the physician practice pressured her in both cases and through lengthy conversations and phonecalls to stay within their practice and "network." My friend, ill, was dumbfounded and confused. Initially, she thought it must be her insurance company attempting to limit her choices (and they were happy to have her believe this). Sadly, she discovered that it was the physician practice itself that was exerting tremendous pressure on her, when she was in fact covered at both the oncology and radiation sites. This type of "managed care" might be great for people who don't have preferences, but they don't work for consumers who have done their homework and have strong preferences for a particular specialist.

Anonymous said...

I am no longer naive enough to think that monetary considerations did not play a role here. However, there is no doubt that the medical information would not have gotten back to the PCP without a major thrash, due to the (sometimes truly life-threatening, if not in this case) fragmentation of our health care system. It appears practitioners are taking the line of least resistance in self defense - as well as the pecuniary benefit.


76 Degrees in San Diego said...

This is not making sense. There are (almost) no referrals for PPO patients. If they go to contracted physicians, they have one price list. If they go to noncontracted physicians, they are subject to a different price list. Perhaps the patient did not actually have a PPO?

Keith said...

From my perspective, there is this attempt by big helath care systems who employ docs to internalize alll health care encounters. EMRs are encouraging this by defaulting to only providers and tests run by the helath car organization with often no option to go out of the system, or the choices are buried and require the user to perform more steps to select physicians ortests not under the health care organizations control. But this is what is coming! ACOs=HMO rehashed with the only difference being that the goverment stood largely on the sidelines last time we went through this and let the commercial insurers take the lead. Now it is the goverment looking to slow cost growth by doing more or less the same and rebranding it as an ACO. How this situation will be handled in the future for those who will pay more for a choice is yet to be layed out by the goverment wonks.

Medical Quack said...

I left this same comment over at the Health Blog...don't trust this information as it is not correct. They get their data from both state boards and insurance companies and in addition, this leads to a feeding ground for fraud as crooks unfortunately mine the web to look for outdated information and could bill with some of this information too.

I can add some information here on the accuracy on online physician ratings and referrals from a couple months ago. I'll also give a link to my conversation with the AMA and together we put together quite a bit of information and tons of errors as I had many doctors write in and comment on the links about dead doctors, retired doctors and inaccurate specialties along with one listing of someone who never practiced medicine.

One more new service opens up and errors in the data base already with using information not updated. The example shows a doctor with a 5 star rating that has admitted to Medicare fraud for the second time.

Here's my conversation with the AMA from their website.

As one more note to interest, Healthgrades too was purchased by a private equity firm and initially the investors thought they sold too cheap, but in my opinion maybe it should have been less when you look at all the errors. Again the one listing as one MD commented is the guy who never practiced medicine being listed. They made millions with getting consumers to subscribe by paying for additional information via a credit card subscription and this is an outrage for both doctors and consumers.

When you read my initial post I found my own deceased obgyn who has sadly been gone for 7 years and yet there was not only Healthgrades but several other sites still listing her as well. Don't believe everything you read on these sites.

One doctor even commented that other MDs he knew were good oncologists looked so bad that he logged on and rated them fairly to help them so they didn't look so bad on the ratings:)

Anonymous said...

As a patient who has a few specialists outside of where my PCP practices, it is difficult to coordinate care when not in the same system. Having said that, You are not wrong!!! However, I urge you to take full responsibility for making certain the specialist forwards her notes, treatment plan, testing and the like to your PCP; and even ask for copies to be sent to you in the event it doesn't make it to your PCP. I have found this route helpful and provider's I've encountered have not taken issue.
It is more important to be a with a provider that you feel comfortable with and will get the best care and treatment possible then to worry about keeping everything in the same system.
Paul, you are likely correct most would have taken the referral without question and that is sad. Even when “special permission” is needed, isn’t it important that a patient see a provider that he/she feel comfortable with than to worry about keeping everything in same system? Not all physicians are equal and if their interpersonal style doesn’t match, all the brilliance in the world will not matter.

Although I’m cautious about, when many patients have weighed in with similar reviews it is important to take note.

e-Patient Dave said...

I forgot to mention - another egregious example, far more serious than dermatology, is the story of Diane and (daughter) Hilary Engelman, whose care plan persistently denied Hilary the correct heart surgery, despite the cardiologist's orders. The surgeons said it wasn't medically necessary.

Well, turns out the real issue is that those surgeons don't do that surgery, so they'd have to send the business outside the company.Which, eventually, the state ordered them to do - but only after three years of persistence by "mama lion" Diane.

Trisha Torrey's blog identifies the plan, and calls this (correctly, I think) A new category for medical errors: doctors selling out. Anyone care to argue that point?

I mean, these big-plan bastards were telling this young woman to hurry up and have babies now, because after the surgery they wanted to do, babies would be difficult or impossible. They were flat-out lying - or seriously misinformed.

The amazing thing to me is that we're collecting story after story like this. When those islands of conversation start to connect there may be explosions.

We'll see.

Anonymous said...

You don't need a referral if you have a PPO.

Anonymous said...

A lesson I learned when I worked as an internist at a large HMO on the west coast, and what drove up costs was, "People want what they want when they want it."
What controls costs is, "You get what you need when you need it." C'mon, it's eczema...

e-Patient Dave said...

Anon "C'mon",

Do you honestly believe a centralized decision group should decide what people need, period? Really?

I wonder if your large HMO on the west coast is the same one where Diane Engleman's daughter was denied the heart surgery she needed.

Nancy said...

Please don't dismiss eczema that easily, anon-11:00. It can be a very painful and debilitating condition and I'd think that if someone was trying to find the very best doctor to treat it, it's possible it's affecting more than a small patch of skin.

I hear this about peanut allergies too. Should it be "c'mon, it's only an allergy" to that too?

-Mom to a child who has an anaphylactic allergy to peanuts and had eczema over 3/4 of his body. I searched for the best dermatologist and allergist that I could find to help him.

Matt said...


I think what anon 11:00 was talking about was the need for the person who had eczema to see a specialist. Eczema is a condition that can generally be treated by primary care. If and only if primary care can not adequately treat a person should that person see a specialist. (I would estimate that 95% of cases of eczema don't need a specialist)

A lot of people who want to see a specialist, don't need to see a specialist. Seeing a specialist does not necessarily mean getting better care than you would otherwise receive by your PCP. (this has been proven for many conditions such as diabetes). When you see a specialist, the specialist is more likely to order unneeded tests and procedures and generally results in higher cost of care. Separating those who WANT to see a specialist but DON'T NEED to see a specialist from theose who both WANT and SHOULD see one is important when you talk cost containment. (and you HAVE to talk about cost containment if you want to have a viable, long term health care delivery system even though no one wants to admit that)

Anonymous said...

What I don't understand here, is why someone who is in a PPO plan would even ASK for a "referral". With a PPO plan you don't need one.

By asking the docs office for a referral, of course the doc office thought the patient was in a managed care/network plan, because those plans require referrals.

It's too bad that sometimes folks make a big deal out of something that wasn't a problem in the first place.

Paul Levy said...

What I don't understand is why you are blaming the patient.

Anonymous said...

Paul, I think people are blaming the patient because the story doesn't make sense. As a primary care doctor, when a patient calls to ask for a referral, it means one of two things : either the patient has an HMO and needs a form to bring to the specialists office so the specialist can bill for the service (ie. gatekeeper function) or the patient wants the opinion of his/her primary care doctor as to which specialist they would recommend for the patient to see for their condition. In this case, the patient didn't need a form and didn't want or like the choice of specialist his primary care doctor recommended. Yet he continued to call repeatedly over the course of more than a month asking for something he didn't need (a referral form) or want (advice). Apparently, neither you nor this patient understand that the patient is just wasting the time of the doctor and his staff and then complaining about it. Now do you understand? And lastly, if patients want more advice or treatment or they just don't understand, they should make an appointment because your insurance company has decided that is the only way your doctor can be paid for his/her services. Now do you understand?