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Consider A Doctor Who’s Not A “Preferred Provider”

Many companies and consumers are turning to higher-deductible health care plans (HDHPs) in order to keep their insurance policies more affordable. The rational basis of these plans is that since you’re using your money and you are in control, you will pay more attention to what is really being offered to you as well as to the cost relative to value. You will be more likely to challenge your doctor to provide the rationale for an expensive test or drug, and to encourage your doctor to innovate to provide lower-cost alternatives.

A trap of these new health plans, as currently structured, is that you’re herded into in-network ‘preferred providers.’  The rationale of the insurance company is that they can control doctors’ prices, thus brokering a better rate for you. They also want to use your loyalty to the network to control physicians’ practices. “Preferred,” in reality, does not refer to quality; rather it just means the doctor has signed an agreement with the insurance company, binding them to the insurance company rules, which favor the insurance company, not the patient.

In most cases, there are good reasons to go out of network for your day-to-day health care. First of all, insurance companies place strict rules on their in-network providers. For example, in-network providers can’t be paid without an office visit, so you’re forced to come to their office for everything, even though evidence shows that office visits are required for less than half of primary care problems. Second, all medical information the in-network provider receives on you is sent to the insurance company.  Insurance companies often will use your health information to justify denials of future care. If you want to protect your confidentiality, don’t go through your deductible. Finally, if you find a doctor who works outside the network, these providers may be able to work more efficiently, with greater access and convenience for the patient, while charging the same or lower prices than the discounted rate provided by the insurance company.

However, most people are reluctant to go outside the network, because they fear it will result in higher cost. Insurance companies warn that if you go to a physician ‘outside the network’ the value of your deductible will double, for example, instead of a $2000 deductible, it could be $4000. This makes it look like going out of network could increase your costs by $2000.

But, in fact, for primary care physicians, this logic does not apply.  Why is that?

1)    There are an increasing number of doctors who are providing primary care at a much lower cost rate than the standard model, either by avoiding the administrative burden of the insurance system, or by finding more efficient ways to provide care.

2)    Most out of pocket costs are not actually to see your family doctor or other primary care providers. Most of the expenses go for laboratory tests, medications, emergency room visits and specialist consultants. For these, you may indeed want to stay within your preferred provider network to capture the discounts on these major costs. But your out of network physician can order these for you, and you can still get the discounts.

3)    Primary care visits with a physician average $400-500 per year; lower-cost innovators like Doctalker Family Medicine —who charge based on time, rather than diagnosis, and avoid insurance-related expenses, and use modern information technology–can provide that service for $300 per year. This is thus a small percentage of the deductible.

4)    Out of network physicians can provide other qualities worth any small difference in price, like convenience, accessibility, patient education, high knowledge base, tailoring care to your needs, patient control.

5)    Many out of network providers can use their flexible situation to hunt out low-cost options for other elements of your care, like x-rays, labs, etc., that may be significantly cheaper than the negotiated rate of your insurance company.

6)    In many years, you won’t go through your deductible, so you won’t move into insurance coverage anyway.  When you do go over the deductible, it is usually because you have had some major health problem—an accident, a surgery, etc,–and then the difference in deductible qualification won’t make any difference. You will go far over the deductible. For example, an ER visit could easily cost $2000; a typical one-day hospital stay costs $10,000.

7)    In many insurance plants, numerous types of care are not eligible to be counted towards your deductible anyway, such as vaccines, travel medicine or weight control.

The bottom line: don’t be distracted by the deductible. Your health is too important. The most important criteria for choosing your primary care doctor should be competence, access and trust. Primary care accounts for such a small percentage of your total health care costs, that you shouldn’t worry about whether he or she is a ‘preferred provider;” this might impact the quality of doctor you choose. Plus you may even save money by going out of network.

Until next week, I remain yours in primary care,

Alan Dappen, MD


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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