Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments

Physician Referrals: Be Daring And Ask For A “Special Order”

As a specialist, one of the saddest truisms about practicing medicine in the private world has always been how little one’s clinical skills determines referrals. Unfortunately, as our present healthcare climate pushes “providers” to consolidate along the lines of major hospital networks this injustice will only worsen.

A decade or so ago when I started private practice it was obvious that referrals came to me because of my association with an established group. This association was essential, as one could have been the next Michael Jordan of electrophysiology, but referrals would still have gone along historic lines, to the favored group. It would have taken a Herculean effort, over years, to encroach upon such long-established referral patterns, etched over the bonds of rituals like Wednesday afternoon golf matches and dinner clubs.

Thus, few specialists start independently. You join an established group, do good work, form relationships and eventually, your quality becomes known. As it should be: Do good work and doctors will trust you with their patients. But yet, even the highest caliber specialists may fall prey to the easily accessible, affable (but unknown and untested) “new guy.” For enhancing referrals, availability and affability trump [actual] skills at least 90 percent of the time.

Now there is a new trump card for referrals: Physician consolidation. Who owns who. For example, hospital X’s primary care doctors refer their cardiology (substitute any specialty) to hospital X’s cardiologist.  And so on with hospital Y and Z.  Like in this example, as one local oncologist bemoaned to me recently: “referring doctor Y used to refer me all his patients, but since the acquisition, he sends his mom and brother to me, but sends the rest of his patients to his new mother-ship’s oncologist.”

My message here is not to cry sour grapes, but rather to echo two themes. First, to mirror the message of the Wall Street Journal’s recent editorial: Although a goal of healthcare reform is to enhance competition, paradoxically in the case of incentivizing provider consolidation, patients’ choices are diminished. You (the patient) will be seeing our cardiologist, or our surgeon, or you will be having your MRI in our (smaller magnet, but less costly) scanner.

The other motive for highlighting these new allegiances is that patients should understand the mechanisms at hand in deciding which specialists they are recommended. Isn’t it fair that a patient know that their doctor may have signed a contract agreeing to use the “company” doctors? (Sure, there was a also a clause in that same contract saying the “company” would not interfere with medical judgement, but we all know that persistent rogue referrals will likely result in an unpleasant fireside chat.)

In employing doctors, the primary master of the profit-driven healthcare corporation is physician productivity — CPT codes and workRVUs are the grading system, the language. The code for an ICD implant is 33249 and its reimbursement is set, regardless of whether it’s appropriate or done right. Hopefully, the companies that employ the best doctors will find ways (besides profit) to distinguish themselves.

Providing higher quality care to millions more at lower costs will surely have its consequences. Undoubtedly for patients one of these will be fewer choices. When eating for free, only the most daring ask for a special order. Be daring.

JMM

*This blog post was originally published at Dr John M*


You may also like these posts

Read comments »


Comments are closed.

Return to article »

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

Read more »

See all interviews »

Latest Cartoon

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.

***

Click here for a musical take on over-testing.

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »