Medical Testing in the Era of Insurance Certification

This morning I started out writing an entirely different blog post but decided to go another route after a painful episode with an insurance company, namely United Healthcare. Why yes, if you read my blogs, this is the same insurance company that denied my patient an antidepressant medication that is the only one in its class. This is the company I tried without success to discuss their rationale with a medical director. However, today was a radiologic procedure I wanted on a patient and was subsequently "invited" to talk to one of their physicians to get approval for it. Does this strike anyone else as odd that I can be essentially "ordered" to talk to one of their doctors but none of them will return the courtesy of my phone calls?

In the last six months medical insurance companies have become increasingly resistant to allowing physicians to order certain studies without certification by them. If you insist that the patient needs the test, then you must have a "peer-to-peer" review in which justification of your need for the test must be made to one of the company's physicians.

As documented in many studies, there are a lot of unnecessary tests that we physicians order for a variety of reasons. Those include liability concerns, patient requests, and concern that you might be missing a rare disease process. Recently the Foundation of the American Board of Internal Medicine developed recommendations from several medical specialty groups regarding tests or treatments which doctors should question the necessity of before ordering, in a document called Choosing Wisely.

I absolutely agree that we, as a healthcare system, are ordering too many tests. The insurance companies way of dealing with the problem is to have a majority of tests, particularly expensive ones, "certified" before they will agree to pay for them. Today I had two of them that apparently did not fit someone's algorithm and needed a "peer-to-peer" discussion. Sighing, I called the number listed on the fax paper request from United Healthcare. Dutifully I hit #4 as instructed. This didn't work immediately because a 30 second introduction had to be finished before option "4" could be chosen. Finally I got through and was instructed to key in the case number. Twelve numbers later, it repeated the number back to me and told me to press "1" if that was correct. Then I got a real person. Up to this point I was OK with how much time I had wasted but the real person on the line was not a doctor. It was someone who wanted to know if I was a doctor and if the patient's name was so-in-so and if the procedure ordered was a such-in-such. Affirming that was the case I was put on hold. About five minutes later I began to seethe.

Have you heard how primary care physicians are inundated with patients, how we don't have time see the patients that we have much less makes sure all our refills are done, referrals letters read, referral letters sent, prescription prior authorizations done, patient lab work reviewed as well as keep up with CME (continuing medical education--you want me up-to-date, right?), patient emails, and any other business of healthcare? Every afternoon there are a minimum of 75 charts to be gone through, lots more on Thursdays (because I take off on Wednesday) and Mondays look like a truck backed into my office and dumped the charts onto the desk, chairs and credenza. Don't even make me think about when I come back after vacation. Well, apparently United Healthcare thinks responsible patient care involves me sitting and waiting on a phone for one of the "peers" to pick it up and determine if my ordering is within their guidelines. This is not something I'm willing to do--so my question to my audience is--should I be willing to? Is this now another part of my job and is it a reasonable thing? Please input, I'd love to hear. 

Please remember that the opinions written in this blog are entirely my own.

Twitterchatting

Last night I participated in my second "Twitterchat". With my first one I was simply a "lurker", sitting in the background, watching the logistics and remarks. The topic of this one was mobile health, better know on-line as mHealth, and was sponsored by a group I follow on Twitter, iMedicalapps. This time I was an active participant as the group discussed several topics--how knowledgeable physicians are about mHealth, how it can help our patients and how to get more physicians to understand and use it.

While physicians have adopted personal use of Facebook and iPads in droves they are much more hesitant to use these tools on a professional basis for many reasons--time constraints, HIPAA concerns, no familiarity with the technology, etc. This Twitterchat's purpose was to address those issues and see if individuals had ideas on how to make changes in physician habits.

After the chat was finished my reflections went somewhere along the lines of "Well that didn't seem to be very helpful." And then it hit me, the actual chat may not have been all that substantive, especially when everyone is talking at once and it is impossible to read all of the comments as they go whizzing by on the Tweetchat screen. What was of significance was meeting these individuals, seeing how they are approaching similar issues to your own and making contacts that could grow into collaborative efforts in the future. To quote Homer Simpson "DOH!"

Somewhere "out there" on the net, I read that Twitter is most akin to a giant cocktail party. It's great metaphor but someday soon I hope to meet many of these fascinating people face-to-face. In the meantime I will lift a glass of wine as I tap my laptop keys and toast to this fascinating new technology.

A Payment Quandary for Medicine and Social Media

These days I spend a lot of time reading other doctors' and patients' blogs and Twitter posts. One recurring theme is the use of Social Media to improve wellness in our patients. This is a great idea and I'm excited to participate especially when the data shows that patients who are on social media are already getting heath advice: PricewaterhouseCooper:

Consumer Activity on Social Media Sites Dwarfs that of Healthcare Companies, Finds New PwC Study on Social Media in Healthcare

But who will pay for this? More specifically, who will pay ME for this? Much as I enjoy answering patient emails, would love to have a professional Facebook presence and am happy to Twitter; all these things take time. And time is not something any primary care doc has much of. Since I do enjoy a life outside of the office, including learning a new language, spending time with my family, trying to exercise a MINIMUM of five days of the week, plus bear primary responsibility for feeding my husband and daughter, and would dearly love to read a book on occasion; in the absence of an obvious ROI (return on investment) to present to the healthcare system that employs me, how do I find the time during working hours to do these things and not get paid? My contract specifically defines how much "face-to-face patient contact" I must have. As long as the present reimbursement system persists when I'm not in physical contact with a patient I am not generating income.

As with any service industry it is difficult for our "clients" (I HATE that word, I have patients not clients), to understand that my pay is directly affected by how many people I see every day, or more specifically, how many RVU's that I generate on a daily basis. This is directly tied to how "sick" a patient is. So the sicker the patient, the more I can charge. Wellness? With the exception of ONE "well" visit per year for the commercial insurance patient, I am not paid to promote wellness or good health at all. Of course I try to throw that in with every patient visit but until primary care undergoes the revolution that it needs and deserves, prevention is not something I can afford to spend a lot of time on with patients.

And that truly, to use the vernacular, sucks. There are doctors out there doing it "right", who have left the traditional practice model to become concierge doctors and by all reports these professionals are happier and more fulfilled in their jobs. My expectation is that this is the reimbursement model we will see in the future but in the meantime, how do I find the time to give patients what they want before they or the insurance companies and/or employers and/or government is willing to pay for that time?

modified 5-31-2012 (misspelled quandary--oops!)