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Opinion | The Case of the Unknown Patient

Just the other day, in the middle of a busy afternoon practice session, I got a high-priority message requesting that I place a referral to a subspecialist for a patient whose name I didn’t recognize.

The reason I didn’t recognize their name was because, in fact, they weren’t getting care with me, or with anyone at our practice, or even anywhere at our hospital. Somehow, somewhere down the line, the patient had called up and scheduled an appointment with one of the doctors at our practice, but never showed up for that appointment. Because the patient had changed the name of their primary care doctor on their insurance card to one of our doctors in advance of that long-ago appointment, the subspecialists in the community who were now planning to see this patient were insisting that we place a referral in our electronic medical record so this patient could get whatever care they were planning to give.

Somehow, the absolute ridiculousness of expecting us to put in a referral, use our staff to process it, and then be medically and/or legally attached to the care of this patient we did not know seemed preposterous beyond words. Our staff actually got yelled at when they explained that they couldn’t process the referral because this wasn’t our patient. They were told that we were interfering with this patient’s care, that somehow any delay to whatever care they were planning to provide was going to be our “fault.”

A Common Process

During the course of the day, we are all frequently interrupted and asked to place referrals for things that we did not know our patients were planning to do, and sometimes for ongoing follow-up with their specialists and subspecialists.

How many times have we gotten that message “the patient is at the (insert name of subspecialist) office right now, they have an appointment scheduled right now, but they won’t be seen until you put in a referral and we process it with their insurance company, right now”?

Out the window went our policy requiring for 48 hours’ notice for the processing of referrals — suddenly we have to stop what we’re doing and become administrative drones for the benefit of the insurance company, making sure that this other doctor gets paid for their services. Sure, I want my patients to see their podiatrist, their dermatologist, their gastroenterologist, to get their echocardiogram and their mammogram done, but how did we let ourselves be put in the role of doing this mindless busywork, the stuff that really doesn’t have anything to do with clinical medicine?

How did we get to this place? And why are we letting others keep us here?

Restrictions Sometimes Needed

At a certain point in the world of the insurance companies and all their rules and regulations, it was somehow decided that a consultation required a referral. In the old days, before electronic medical records and the processing of referrals for a certain number of visits that are covered and allowed by the insurance company, we got our patients to see these specialists by giving these doctors a call and asking them to see the patient. Or we wrote a prescription for a mammogram, or an x-ray, or a CT scan, or for a wheelchair or a walker, and then these things were scheduled. They happened; they magically appeared.

Nonetheless, I can certainly see some benefit of some restrictions on what can happen. If every time a patient has a headache, they decided to get an MRI done on themselves, the system would be overwhelmed to the point of shutting down, and nothing would get done. Primary care doctors can certainly serve some role as gatekeepers, helping to figure out what needs a subspecialist visit, what we can manage on our own, and what may in fact best be served by some sage advice, symptom-directed care, and a tincture of time — not another MRI.

But just how did we allow ourselves to be dropped into the middle of all this bureaucratic nonsense, this placing of referrals, this endless amount of office work, support staff time and effort, faxing and emailing, logging onto websites for the insurance company, getting prior authorization, click, click, click?

Here’s a Better Way

I’m sure that somewhere down the line, some of the people working at the insurance company realized that this process would save them money, prevent unnecessary care, and avoid overutilization of services. I don’t think there’s anything wrong with making sure that everybody involved in a patient’s care is aware of what’s being done, and that we’re not doing too much, because sometimes too much of a good thing can be bad.

But why should I ever have to stop what I’m doing for a patient of mine to get a referral for their mammogram? If they are due for it, let them schedule it. Let the Radiology Department reach out to the insurance company, tell them that this thing is going to happen whether they like it or not, and that they’re going to pay for it. The insurance company should know when their last one was; they paid for it last year, so that shouldn’t be an issue.

Sure, they need to attach my name to the order so they have somewhere to send the report, and so we can safely make sure that things get followed up correctly. But why do I have to stop what I’m doing and become a data entry clerk, clicking away at the electronic medical record, finding the right mammogram order, answering all the required questions, finding the right diagnosis code that will get it covered, signing the order and sending it over to the right people? Even if that only takes a few minutes, repeat it dozens of times a day, hundreds of times a week, thousands of times a year, and you’ve got the makings of a system that’s destined to fail, destined to break the backs of the patients and doctors it was put in place to serve.

It’s time we demand a system that makes it easy for our patients to get the care they need, where and when we want them to have it. Let’s rethink the rules, flip the system on its head, and create a kinder and gentler system that puts the onus on someone else and lets us get back to taking care of patients.

That’s an order.

  • Fred Pelzman of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine from the perspective of his own practice.

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