White Coat Underground

As my regular readers know, I’m not a big fan of our current health care system. Our bloated, industry-driven system manages to deliver less effective care at a higher cost than most other industrialized nations. The system is Byzantine, unnavigable, and dangerous, and is kept that way in the name of the Holy Market. But health care can benefit from practices that are decidedly un-capitalist, at least in the Milton Friendman or Ron Paul sense.

Like aviation, health care must apply risky and expensive practices to large numbers of people in dangerous situations. This process is made safer by certain sorts of standardization, such as checklists. Data suggest we would also benefit from developing widely applied, evidence-based best practice guidelines, and from increasing the use and interoperability of electronic health systems. But that’s not how we do things here.

Our culture is strongly biased against centralized anything, which is often a useful instinct. But in health care, the market does not necessarily drive best practices, but most profitable ones. One of the worst hybrids of the ultra-free market ideal and the more communitarian ideal is the HMO. It’s not that the idea is inherently bad, but its implementation has often been problematic.

An HMO is an agreement between a patient, a physician, and an HMO. The patient pays a premium to the HMO, and co-pays to doctors and other providers. These fees are usually significantly lower than in other types of plans. The HMO assigns them to a primary care physician and agrees to pay for care the PCP recommends, within the guidelines of the plan. This puts the PCP in the position of “gatekeeper” for more complex medical care. The doctor is often payed less to care for HMO patients, but in exchange the HMO sends them patients and keeps them busy. But this system is often a loss for both the doctor and the patient.

A common way doctors get paid by HMOs is “capitation”, that is, getting paid per head. An HMO will offer a doctor x dollars per month per patient. This reduces the incentive for the doctor to provide unnecessary but potentially profitable care. In fact the incentive is exactly the opposite: the more patients the doctor enrolls, and the fewer services she provides, the more she and the HMO will profit. Basically, HMOs are designed (in their classic form) to give the appearance of providing efficient low cost care, while actually providing inefficient, low cost care that can be minimalist at best.

Many of my colleagues argue that a single-payer system would amplify this effect, as the government, acting as the insurer, would basically enroll us all in a giant HMO. The actual government approach to care is more complex. The VA is a model of a centralized, self-contained, single-payer system. Medicare functions as more of an open single payer system where patients can choose where to get their care. And Medicaid tends to be a mix of government-administered plans and plans run through private HMOs.

I had a hard time digging up statistics, but as of about ten years ago about 60 million Americans were enrolled in HMOs. Government agencies such as those listed above often contract with HMOs run by the private sector. TRICARE, the plan for military personnel and dependents, offers many different plans, but give strong incentives to use their HMO, TRICARE Prime. TRICARE Prime is offered by the government, but run by a private company, so it cannot be accused of being “socialist”. But it can be accused of being insane. Like most HMOs, it requires enrollees (i.e., people) to select a primary care physician and to get most care approved by that physician. But what happens when that’s not possible?

A reader sends me the following (names have been changed, etc. and all emphasis mine):

Is it ethical or not for a primary care physician to make a referral for a patient he/she has never seen?

Background:
Recently I found myself out of town at the same time I was between PCPs. My original PCP was at a facility that was closed with less than a week’s notice.

Shortly thereafter, I finally found a civilian physician willing to take a Tricare Prime patient and faxed the papers to Tricare. I was told that any request received before the 20th of the month would take effect on the 1st of the next month… if approved.

During this window period, I developed stomach pain and a fever. The next day I tried to get a referral from my insurance for a visit to an urgent care clinic. I was told this could not happen without a referral from my PCP. At the time, I thought I did not have one, but was informed that my new PCP became effective upon receipt of the fax — April 17.

My new PCP refused to give a referral, as I expected because she’d never seen me.

Anyway… I went to an ER (no referral required) and was admitted for surgery for [a life-threatening surgical condition]. The surgeon questioned me about the surroundings I’d be released to after surgery and recommended certain home health accommodations.

Since home health also required a PCP referral, I paid for them out-of-pocket. I won’t try to get reimbursed for these services because they really were minimal, but I’m quite angry about the whole thing. At one point, a Tricare Prime representative told me that I would also have to pay out of pocket for the follow-up appt. with the surgeon. The surgeon’s office subsequently assured me that was covered under his fee for the surgery… but it still made me angry.

It seems to me that IF a PCP is required for referrals, that Tricare Prime cannot allow a situation to occur where one would be without a PCP and that they cannot require a physician to act unethically.

That’s why I would like an unbiased view of the ethics of a physician signing off on a referral without ever having seen the patient.

Thank you for taking the time to read my email.

Fascinating. And not atypical. It seems that even the HMO employee didn’t understand all of the intricacies (such as the surgeon’s fee covering follow up appointments). It wouldn’t surprise me if some of the services she needed were actually covered. But that wasn’t her question. She was very tolerant of her HMO, and has a question about ethics.

A doctor who took care of her for a serious condition recommended a particular treatment in order to safely leave the hospital (home care). The HMO required (per her report) that the PCP (who had yet to meet her) order the care that the surgeon required of her. But she did not have a chance to see her PCP before becoming gravely ill. Should the PCP have just gone ahead and ordered the service?

As with most ethical questions, it depends. If a physician orders a service and assumes the care of a patient, they must document this care. For home care, a physician must order the services and evaluate the progress periodically. My patients receive home care all the time. Usually, I order it on discharge from the hospital, but sometimes directly to the home. I must send in an order for services with a diagnosis, and must sign off on updates indicating that I know what’s going on and approve of it.

The general principle is that a doctor should not treat a patient they don’t know. How can the patient’s PCP sign off on care without even knowing what the patient does or does not need? Is it even legal to order home care without evaluating the patient and documenting this evaluation?

Whether it’s legal or not, it’s unwise. I don’t think it would be ethical to order services for someone who I, or a clinician I am supervising, has not personally evaluated. But what about other ethical principles such as beneficence and nonmaleficence? If I, as the HMO doctor, have been assigned to care for a patient, don’t I have ethical responsibilities to them?

Yes, but they are limited. Nonmaleficence includes withholding services that are unnecessary. It requires that I make sure that care I order is appropriate. The entire SNAFU detailed in the above letter is a nightmare for the patient and the doctors. The surgeon needs to provide a covered service but cannot. The primary care physician presumably wants the best for all her patients, not just the one’s she knows, but her hands are effectively tied.

This is, in short, not a problem of individual ethics, but of societal ethics. When we create insane barriers to proper health care, we have made a societal decision that we don’t value the health of our citizens. We may all have different ideas on how to solve this problem, but anyone who thinks this is normal or sane gets a stern wag of the finger.

Comments

#1 Keith Harwood
May 26, 2010

“we don’t value the health of our citizens” This has been obvious for many years to those of us who do have universal health care.

“how to solve this problem” It is equally obvious that for American society as a whole, this is not a problem.

The take-home message of `Avatar’, established at the beginning, is that a couple of centuries from now America will have ships to the stars, but still won’t have universal health care.
#2 Pascale
May 26, 2010

The ideal solution in the vignette would have been for the new pcp to meet the patient post-op to help with care.
Of course, we are getting faxes twice a week telling us our patients must fail a course of PhosLo before they can go on calcium acetate… Which is the generic name for PhosLo! I wonder how much they are wasting sending out faxes?
#3 anonymous for now
May 26, 2010

#2, Pascale — I am the patient in the vignette and what I did not include in my email to PalMD was that out of town was 1200 miles out of town. I traveled outside my Tricare South region to Tricare West.

My new Tricare South PCP could not meet with me until I was well enough to travel 1200 miles.
#4 anna
May 27, 2010

HMO’s are pure evil. A corporate pillaging of money, time, resources, skills, patience and preservation of good health.

At one point in the 90′s I lived in Chicago, and through an artist’s guild was able to buy into an HMO healthcare plan. (My family chipped in to help me pay separately for a Blue Cross catastrophic coverage plan).

I never saw the same Dr. twice, my file never seemed to contain the information or bloodwork from previous visits to the same clinic, I had to make special visits just to get a referral- despite the fact that a week before the Dr. had suggested I see a specialist but couldn’t actually issue the referral at that time, and several times- no kidding- had treatment for unresolved conditions halted prematurely because the HMO’s compensation limit had been reached before the problem was fixed. Hello???

This felt like an absolute exploitation in all possible ways, of all people involved.
#5 CanadianChick
May 27, 2010

As a Canadian, one of the things that bugged me the most was the insistance by some Americans that our system was like an HMO. The only similarities are that the GP is like a gatekeeper (sort of) and there is a single payer. What we don’t have is the insanity, rigidity and profit motive!

If I was anonymous, I’d be questioning the ethics of the HMO for leaving you in that situation, not the PCPs. (under our system, the ER doc could have made all the orders for home care, etc)
#6 Dianne
May 27, 2010

I’d like to say that was the most outrageous thing I’d ever heard of an HMO doing. Sadly, it isn’t.
#7 edselpdx
May 27, 2010

The incentive system of reimbursement is one major problem with for-profit healthcare systems. The standards of reimbursement should be based on things like what percentage of your patients are up-to-date on things like colorectal cancer screening, or adolescent immunizations, or mammorgrams, not on how many patients you can squeeze onto you panel of primary patients. When you prescribe an antidepressant, is that patient seen back in a reasonable period of time to recheck symptoms? Did you arrange (and document) a recheck of blood pressure for the woman you started on an ace inhibitor?

Another biggie that bothers me is surgery referrals for example on a Medicare patient. Your patient has a bum hip, and goes to see an orthopedist. The orthopedist in private practice gets paid significantly more to do a hip replacement than to recommend PT or other non-invasive therapies. The surgeon has an office staff to pay, so what do you think the incentive is? Surgeons are paid to cut.

Oh, don’t get me started…
#8 another anon
May 27, 2010

Another aspect of this is that they’re set up to waste the patient and the doctor’s time, in ways that if I’m feeling kind I assume are just pointless. If I’m feeling cynical, I assume they’re designed to reduce care and thus spending.

Consider the patient with a chronic condition that requires them to see a specialist. The HMO requires, before every visit, an authorization from the PCP. That’s wasted paperwork that the PCP’s office isn’t paid for, to every n months say that yes, this person still has this chronic, incurable condition. And yes, still needs to see the specialist. Each “referral” form looks the same, except for the date.

They then require the specialist to periodically reauthorize the patient’s medication. This isn’t “we want the doctor to look at things.” The doctor does that anyhow, by renewing the prescription. (A doctor who will renew an Rx without seeing the patient is unlikely to insist on seeing him before having his office call the insurance company to say that yes, their patient needs the medicine they’re prescribing.)
#9 Eric Lund
May 27, 2010

A doctor who took care of her for a serious condition recommended a particular treatment in order to safely leave the hospital (home care). The HMO required (per her report) that the PCP (who had yet to meet her) order the care that the surgeon required of her. But she did not have a chance to see her PCP before becoming gravely ill.

That’s some catch, that Catch-22.

The emergency room exception to the referral rule is absolutely necessary, in part because cases like this do arise. But it gets problematic at the back end in cases like this: she can leave the hospital if she has home care (which the PCP she has not yet been able to see will not authorize), or she can stay in the hospital (which the HMO will not cover because it is not medically necessary if she can leave with home care). IANA M.D., but doesn’t the Hippocratic Oath demand that somebody make an accommodation here?
#10 PalMD
May 27, 2010

There is not much the individual docs can do. And studies have shown that doctors will lie to help patients get what they need—that is a horrible way to do things.

http://archinte.ama-assn.org/cgi/content/abstract/159/19/2263
#11 Jim
May 27, 2010

This isn’t related to the HMO but the health care insurance industry as a whole. My wife and I always put off seeing the doctor due to costs of deductibles and fees we have to pay on procedure, even though we are considered as having pretty good health care. We have a $500 deductible, then we have pay fees on procedures.

Recently my wife had some tests performed which the insurance company said that they were performed by an out of network lab, which they were, but the doctor’s office claimed that there were no in network labs that performed the tests. After going back an forth several times and delaying payment, the lab finally reduced the amount and we paid that money just because it was becoming such a hassle.

Another example is when I had my colonoscopy I had to pay almost a third of the cost because the insurance company said it was performed in a hospital, if it had been performed in a clinic it would have been covered. WTF? It’s still the same thing, and if I had known ahead of time, which is difficult at best, I would have found a clinic to perform the procedure.

So now we are scared to go to the Doctor’s in the fear that every visit will result in hundreds or thousand of dollars in fees. Again we are considered as having better than average insurance coverage. Anyone that thinks our health care system doesn’t need major changes is on drugs.
#12 bsci
May 27, 2010

As a general aside, there are other HMO models than the one you describe. For example, Kaiser Permanente is an HMO, but all the primary care doctors and many of the specialists are direct employees of the insurer. As a personal anecodote, I haven’t been in a situation where I needed to test the limits of my Kaiser insurance, but it’s the best run and most competent health system I’ve ever been a part of.

Also, I wasn’t able to dig up the reference, but a study from about 10 years ago showed little difference in customer satisfaction between PPOs and HMOs, but a large portion of the people who liked their HMOs incorrectly thought they had a PPO.
#13 D. C. Sessions
May 27, 2010

So now we are scared to go to the Doctor’s in the fear that every visit will result in hundreds or thousand of dollars in fees. Again we are considered as having better than average insurance coverage.

And you do — see how well it works?

Anyone that thinks our health care system doesn’t need major changes is on drugs.

That’s sort of the point, no?
#14 katydid13
May 27, 2010

Is it ethical for a primary care physcian to make referrels for a patient they know, but have not seen for that specific condition?

I’ve had that happen twice and it seems to me like a primary care visit would have been a waste of time. Both times, I ended up in the ER and was told to follow-up with an orthopedist. However, I needed a referral from my primary care physician, which she gave me without seeing me.

Both cases were fairly simple. In one I fell and managed to get several nondisplaced fractures and in the other slipped and dislocated my knee cap.

I have a great relationship with my primary care doctor, but I’m not sure what seeing her would have added.

The second incident was when I dumped my HMO for Blue Cross Blue Shield after have a conversation with a customer service rep telling me I had to go to either Baltimore or Richmond to get an MRI. I live in DC. I have insurance through the Federal Employee Health Benefits Plan. So not being able to get an MRI in DC was insane. One part of the exchange included the employee saying maybe there weren’t any MRI machines in DC. There was of course database error, but it took more phone calls than it should have to straighten that out.
#15 anonymous for now
May 27, 2010

#5, CanadianChick – Don’t worry about me questioning the ethics of Humana, the Tricare Prime contractor or the DOD! Getting outside opinions about whether they are asking doctors to behave unethically is a part of that.

As to rigidity and insanity, yep we got it. The profit motive should NOT be there. Humana told me they were only following the rules set up by the DOD in their contract. They lost that contract in January, but it was extended by the GAO by one year while some discrepancies in the RFP and the DOD pick of the winner (United Healthcare) get sorted out.

Granted, I talked to several people at Humana and got conflicting statements, but I’m not going to say the DOD wouldn’t create a catch-22

#9 – Eric Lund: That’s the way I think too — that there should be some way for an accommodation to be made in an unusual circumstances like this one.

#8 – another anon: I did not have referral problems like that with Tricare Prime. With one exception, all the referrals to specialists I’ve got have been for 4 visits and good for one year. Prescriptions are not a problem either, since they are separate from Tricare Prime.

To all – thank you for your thoughts and keep ‘em coming.

I’m back home now (my poor hubby rode a Greyhound bus for two days to drive me back – now THAT’S love). I’ve seen my primary care doc and I’m healing fine.
#16 Shannon
May 28, 2010

Surely a “temporary PCP” status could be conferred to a treating physician in a case like the one described above? How difficult would that be, really? the formally listed PCP, who has never seen patient, defers status to most recent treating physician, w/ a possible caveat, WITH REGARD to care needed based on whatever original treatment was provided by that surgeon, until such time as original PCP can see patient and “take over” again. It’s probably a matter of two doctors signing one form, and then having the patient sign it.

I still think single payer would be best, though. I was sorry we did not get a public option.
#17 OleanderTea
May 30, 2010

Another Anon said:

Another aspect of this is that they’re set up to waste the patient and the doctor’s time, in ways that if I’m feeling kind I assume are just pointless. If I’m feeling cynical, I assume they’re designed to reduce care and thus spending.

That’s exactly the point.

Also, it’s in the hopes that patients will get sick of all the paperwork, conflicting answers from the CSR staff, delays, and other bullshit, and just pay for their care out-of-pocket. (Example: every time I see my pain management doc, my insurance company asks me if the condition is due to a work injury or auto accident. No, it *STILL* isn’t, and you’d think they’d catch on after three years.)

I have worked in health insurance for almost two decades. I thought I knew all of their tricks, but I am positive they’ll come up with more to slimily get around the recently-passed laws designed to get patients the coverage they paid for.
#18 bsci
May 30, 2010

OleanderTea
I just want to note that the paperwork isn’t an issue of HMO vs PPO. For a personal example, I was involved in an offspring generation project once with a PPO (Blue Cross) and once with an HMO (Kaiser). For the PPO, every visit to the doctor was a separate form and bill. Every test was another separate form and bill. If the names were written slightly differently from the insurance file, they’d sometimes deny coverage requiring another phone call to customer support.
For the HMO, there was some initial paperwork once the pregnancy was confirmed. The only redundant paperwork was that the hospital where we were delivering had it’s own packet of information from us that they wanted (which they promptly lost and we had to fill out again). Once the baby was born, there was a single bill for the entire pregnancy/delivery process.
In general, with my HMO, I can schedule most appointments online looking at a calendar of a doctors available slots (almost always something available at a convenient time within 2 weeks). For me, time and aggravation savings from having an HMO have been huge.
#19 OleanderTea
May 30, 2010

bsci, then you are very, very lucky with your HMO. And a good thing, too, since it involved a pregnancy (at which time you’re stressed enough without having to worry about insurance). But the fact is, that’s not how it works for a lot of patients, and it’s not how it works for most docs, either.

Ironically, I have a PPO, which is nearly as big a pain in the butt as my HMO in the early 90s was. But these days, you can’t really make a blanket statement which one is better from a patient’s POV.
#20 bsci
May 30, 2010

I wasn’t lucky. We did the background research and selected an HMO that had a strong reputation for the types of things we knew we’d used. My point here is you could never make a blanket statement which is better for patients. Saying insurance is lousy for being an HMO is giving the company an easy excuse for being lousy.

No system is perfect, but there are ways to do PPO and HMO style insurance well. Even the government supported single payer models work off these types of models. Figuring out what works with each model is beneficial whether the government or private insurers are paying.
#21 gaiainc
June 2, 2010

Insurance companies are not in business to take care of people. They are in it to make money. Period. Making processes as rigid, stupid, and illogical as possible makes it more likely that someone will give up and give in instead of fighting the good fight. I’ve had to change a prescription for glucose testing strips because it couldn’t say TID-QID testing. It had to just say QID. Why? No flipping clue. This is now the third or fourth time I’ve had to write this prescription. And the insurance company doesn’t want to cover QID testing, just TID, because my patient has made “great strides”. Yeah… the HgbA1c is now a single digit instead of double-digits, but it is still too high and the only way I can manipulate the insulin dosing is by knowing what the CBG’s are fasting and after meals. Testing QID costs the insurance about $1 more per day, maybe $365 or $366 a year assuming they pay for the whole cost of the testing strip (which they usually don’t). A hospital bed costs on average $1000 per night. That’s just the bed. That does not include physician, nursing, testing, or medication costs. Can we say penny-wise and pound-foolish?

GAH!

I also get letters from pharmacy benefit managers or even insurances themselves who tell me I’m supposed to change a patient’s prescription. Usually this is because the PBM or insurance suddenly has realized that my patient is on a medication that they’ve decided to limit and they want my patient to go through step-wise therapy. They will ignore the fact that the patient has been on this medication for the past 2+ years and has been doing well. My usual response is to write the PBM or insurance a pointed letter asking them why they want to risk the patient having a bad outcome just so that they can save some money. Usually, they back off and approve the medication. However, I still have to take the time to write the letter and we have to wait for their response. It’s fricking stupid and frustrating. At this time I refuse to give in to the inane bureaucracy and I keep firing back at the damn insurers so that my patients might be able to get some care.

Thus, the above story doesn’t surprise me at all. It also reinforces for me the need for universal health care. What the US has now is complete crap. And I’m ranting and I need to stop.