"What many physicians find is that
the rhetoric and promises made by insurance companies canít
meet the restrictions placed on physicians."
Caught in the middle
Physicians take the brunt of patient hostility when insurance companies promise enrollees lots of benefits then tell doctors they canít provide the service
by Sandra Lee Breisch
Itís a common scenario: a patient comes in with a lower back problem. After a thorough examination, perhaps a few X-rays, the orthopaedic surgeon informs the patient that he or she strained a muscle.
The patient insists that the physician order an MRI scan, even though the condition does not require such an expensive test. The physician denies the patientís request, based on his or her expert opinion. The patient is suspicious and mentions a recent television program that portrayed physicians involved in kickbacks with some managed care program.
"This scenario can create a volatile situation for the caregiver," explains Paul Calvin Collins, MD, an orthopaedic surgeon practicing in Boise, Idaho. "The patient is feeling that the doctor is withholding a test or procedure when in fact, the doctor is trying to be their advocate."
Yet, the real issue, notes Dr. Collins, is, "Youíre dealing with patient frustration over a health care plan. Itís a misunderstanding, either inadvertent or oftentimes, by design of the plan."
Patients have to be educated to understand that youíre not withholding a test, explains Barry Dorn, MD, an orthopaedic surgeon and associate director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health.
According to Dr. Dorn, this situation can be resolved if the physician spends an extra few minutes to make the patient understand the value of the test and how the test is going to benefit him or her. "Explain to the patient: 'An MRI would be very helpful if we plan to do surgery or if there were any question in mind that we might do surgery. Iím not making money by not ordering your test. Iím trying to treat you in an appropriate cost-effective fashion. And if I donít do that, then your health premiums will go up next year and youíll be unhappy."
Dr. Dorn is a consultant and frequent speaker to medical and other health care groups on the topic of negotiation and conflict resolution. He stresses that the physician should encourage patients to ask questions and voice their complaints. "This is really a physician-patient thing. What the physician has to understand is that this is a continual education process with the patient."
Yet, orthopaedic surgeons are not the only ones who are having a tough time dealing with patient complaints. Dr. Dorn cites an example when he wore the consultant hat for a health maintenance organization (HMO). "They told me, 'Weíre getting a phenomenal number of patient complaints. What should we do?í"
"Encourage everybody to complain," recommended Dr. Dorn.
The client responded, "We have to pay you a lot of dollars for that advice?"
Dr. Dorn retorted, "Yes, because if you get the complaints out, encourage people to complain, address the specific issues on the table, youíll solve the problem. But if you spend all your time trying to squelch the complaint, you donít get anywhere [with the patient]. You just get unhappy people."
Hereís an even more common situation provided by Dr. Collins: a child comes in with a finger fracture two weeks after a reduction is necessary. The mother or father says, "Why wasnít this done before. Why didnít we get referred to you right away?"
The orthopaedic surgeon, notes Dr. Collins, is saying to himself, "This is going to be tough."
The surgeon responds, "Because your gatekeeper did not refer you to me in a timely fashion and should have referred you sooner."
According to Dr. Collins, the second situation is squeezing an even tighter vice on the orthopaedic surgeon. "Not only does he or she have to deal with the needs of the patient, but also the relationship to the referring physician, which may be contractual," he explains.
Stresses Dr. Dorn, "You donít want to offend the patient or the referring physician. So, I usually say, 'Your finger needs to have a rod put in.í If the patient asks 'why didnít my doctor send me in?í I say, 'I really donít know. I donít know what all the circumstances were.í What is important, though, is telling the patient: 'Iím sorry that you had a delay of two weeks and, hopefully, we will be able to fix this without difficulty.í"
According to E. Michael Kelly, a Chicago attorney at Hinshaw & Culbertson, "Editorial comment by a physician is never appropriate."
But what is appropriate, says Kelly, is proper documentation on the patientís chart to prevent the possibility of a malpractice suit. He advises jotting down simple facts on the patientís chart such as, "Patient injured the finger two weeks ago. Came in today, X-ray shows a fracture. Iím going to put a rod in it tomorrow at the hospital."
How does a simple statement protect the physician?
"It clearly documents what he or she has done in compliance with the standard of care," explains Kelly. "What it doesnít do is comment on anything another health care provider, physician or an HMO has done thatís either right or wrong. That is the best protection that physician can have against being sued."
Also, if you anger the referring physician, it is not an effective strategy either. "It may make you and that patient feel better, but the referring physician only learns that he or she may not send you another patient," explains Dr. Collins.
Criticizing the performance of a primary care giver or other referring physician can possibly get everyone sued, including the orthopaedist, says Kelly. "The hardest thing is to remember: 'What is it you want to achieve?í That can seldom be achieved by getting angry, getting in someoneís face or drawing a line in the sand. Itís better to take a breath. Then, try to figure out a way to negotiate a mutually acceptable resolution of the situation."
Orthopaedic surgeons also attest to much difficulty seeing patients outside of the referral pattern - patients whose insurance carrier wonít pay for orthopaedic care.
In these instances, Steven Ernest Tooze, MD, an orthopaedic surgeon in Dover, Del., says, "We go right to the insurance company and say, 'Weíve got time to see this patient. Give us approval.í Basically, theyíll work with you. They do give you a struggle, though. Sometimes, weíll even go to the insurance commissioner and pass the gatekeeper. If we need an out-of-state referral, weíll really push hard."
But many busy orthopaedic surgeons such as Barbara Lim Messineo, MD, who specialized in sports medicine, in Winchester, Mass., do not have the time, energy or resources to go to the insurance commissioner with a complaint.
"Itís like having one foot on the highway and one foot on the back of the tractor trailer," says Dr. Messineo, "You canít say no to seeing somebody when youíve contracted with the organization to see their patients. People come in whoíve had an accident and clearly need surgery. Your obligation is to take care of them. You have an obligation to your hospital, your conscience. You do take care of them whether or not youíre going to get paid."
According to Dr. Collins, many plans wear two faces. "The plan wants to tell the patient, they get more taste, less filling - more benefits, lower cost," he says. "Then they turn around to the doctor and say, 'If you give them one more thing, weíre going to financially harm you - especially if youíre in a capitated plan,í which I am not."
What many physicians find is that the rhetoric and promises made by the insurance companies donít meet the restrictions placed on the physicians, says Dr. Collins. "We see this with the important things such as with surgery, with tests like MRIs, where companies give people literature that says, 'Get complete care and get your problems taken care of.í"
This puts a physician or his office staff in an uncomfortable situation with the patient. Dr. Collins believes many insurance companies misrepresent what their coverage really provides. "I think they do this on purpose," he says. "They tell the patients, 'You can have anything you want.í Then they put restrictions on the physicians. So physicians are the ones that end up saying no."
Many emergency surgeries are performed outside of the patientís referral pattern or on people not covered by a plan. The risk of not getting paid is high. Says Dr. Messineo, "You donít necessarily resolve these problems. Some people will go to the insurance commissioner to do it. Most of them donít have the time, energy and resources to take it to city hall. So, basically, you take a loss."
To resolve many of these insurance issues, Dr. Dorn believes the insurance carrier "should offer an ombudsman to deal with the patient or someone who is well-trained and knowledgeable about medicine."
Dr. Dorn recommends that his colleagues take a course in health care negotiation and conflict resolution to deal with the restraints put on them by managed care, resolve patient care disputes and learn about negotiation and mediation methods.
Stresses Dr. Messineo, "You try to remember that you went into medicine to take care of patients, and not to make money because thatís exactly what is happening."