Re: Wall of shame documents

[Guest guest]

Wow, Gordon, I love it when passionate outrage sneaks in between the lines of one of your entries. I have often placed the calls for prior authorization from the examining room, with the patient listening-in, and the speaker-phone button pushed ... Patients do appreciate the effort, and share my disappointment when we get turned-down together (being required by the nurse in Atlanta, or St. Louis, to document that they failed to get good response to Neurontin, and that they had bad side effects from 2 different tricyclics for the neuropathic pain, before they would open the purse-strings to help them pay for the Lyrica which worked so well when the rheumatologist gave them some free samples ...). One day, the lady on the prior-authorization line realized that I was on speaker phone, and she insisted that I had to hang-up and call back on a different line, or she would hang-up on me. I tried to get her to bring her superviser to the phone, but he was in a meeting ... Oh, shucks. I am sure that the one-party-payor system in Canada has flaws, but this system is just rotten to the core. The public is mostly unaware of how amazingly complex, time consuming, and trivial our work is when we’re not in the room with them. To help make the point, it is helpful to have on hand the policy documents you receive from insurers. I love the 8.5x14 inch double sided documents from BCBS I used to receive inRochester NY telling me in 9pt type all the variations for co-payments. The co-pay varied based on the type of visit, the employer contract, and the type of plan(s) chosen by the employer. I imagine a wall in each of our offices (waiting room wall would be good) that is papered over by the documentation requirements for prior authorization, the documentation requirements for CPT codes, the auto-rejected claims based on down-coding engines, the rejected claims. I imagine a collage showing how many times you have to re-submit to get paid a fraction, and what happens when a patient has Medicare primary and a supplemental insurance. We could paper an entirely different wall with all the formularies from the different insurers (make sure to point out that they get legal kickbacks from the pharmaceutical industry to steer their “members” to certain drugs. Some other techniques I love:Have the patient sit in the room with you as you try to obtain prior authorization. Make sure to do it on a speakerphone. One of my favorite anecdotes is a doc who asks the patient “Do you have a cell phone?” The doc then borrows the pt’s cell to call the insurer & says “come get me in the next room when you get through the ‘on hold’ line.” You could create a laminated sheet that tells patients how to “press 3 for …” etc. Ask your patients to call the insurer to ask why a claim wasn’t paid and come back with the answer. Have a separate phone in the waiting room and ask your patients to verify their insurance status and check on the co-payment for every visit (like we’re supposed to do). Give your patient their list of recommended prescriptions and have them try to find on the web or phone if these meds are covered and at what co-pay and at what pharmacy. As I type this list I sit back and think “gosh, this is starting to seem cruel.” And then I think “IT IS CRUEL!!!!!” How can we keep up with this nonsense!?!? The public must be made aware that this is way beyond “annoying paperwork” and into the land of “we can’t even get to our work for you because we’re drowning in this insanity!” We’ve had 20+ years of the experiment in managing “care” through price control, prior authorizations, formularies, case management, disease management. Many executives hold up graphs showing improved generic prescribing rates, improved cost of care of high illness burden patients, reduced A1c burden for patients with diabetes. These are good things, but have we seen an overall improvement in clinical outcomes, patient experience of care, total cost of care? We know all too well that proximate outcomes may not lead to the ultimate outcomes we need. It is time to pull the plug on this experiment, it is hurting our patients, it is hurtingAmerica. It is time to follow the data demonstrating the worth of effective primary care.We need the resources to pursue our professional obligations for our patients. Gordon

[Guest guest]

If pt gets service, I doubt they care about "our" burden.

Sometimes the contrarian.

Just do it better.

By the way, the "exceptional care" we give our pts as IMP or "IMP like" should speak worlds to the pts. I for one am getting alittle put off with the position of having to "prove ourselves" with demonstration projects, etc.

Matt in Western Pa.

Surviving after 4 years (starting 5th year Dec 1)

"Wall of shame" documents

The public is mostly unaware of how amazingly complex, time consuming, and trivial our work is when we’re not in the room with them.

To help make the point, it is helpful to have on hand the policy documents you receive from insurers.

I love the 8.5x14 inch double sided documents from BCBS I used to receive in Rochester NY telling me in 9pt type all the variations for co-payments. The co-pay varied based on the type of visit, the employer contract, and the type of plan(s) chosen by the employer.

I imagine a wall in each of our offices (waiting room wall would be good) that is papered over by the documentation requirements for prior authorization, the documentation requirements for CPT codes, the auto-rejected claims based on down-coding engines, the rejected claims. I imagine a collage showing how many times you have to re-submit to get paid a fraction, and what happens when a patient has Medicare primary and a supplemental insurance. We could paper an entirely different wall with all the formularies from the different insurers (make sure to point out that they get legal kickbacks from the pharmaceutical industry to steer their “members” to certain drugs.

Some other techniques I love:

Have the patient sit in the room with you as you try to obtain prior authorization. Make sure to do it on a speakerphone. One of my favorite anecdotes is a doc who asks the patient “Do you have a cell phone?” The doc then borrows the pt’s cell to call the insurer & says “come get me in the next room when you get through the ‘on hold’ line.” You could create a laminated sheet that tells patients how to “press 3 for …” etc.

Ask your patients to call the insurer to ask why a claim wasn’t paid and come back with the answer.

Have a separate phone in the waiting room and ask your patients to verify their insurance status and check on the co-payment for every visit (like we’re supposed to do).

Give your patient their list of recommended prescriptions and have them try to find on the web or phone if these meds are covered and at what co-pay and at what pharmacy.

As I type this list I sit back and think “gosh, this is starting to seem cruel.” And then I think “IT IS CRUEL!!!!!” How can we keep up with this nonsense!?!? The public must be made aware that this is way beyond “annoying paperwork” and into the land of “we can’t even get to our work for you because we’re drowning in this insanity!”

We’ve had 20+ years of the experiment in managing “care” through price control, prior authorizations, formularies, case management, disease management. Many executives hold up graphs showing improved generic prescribing rates, improved cost of care of high illness burden patients, reduced A1c burden for patients with diabetes. These are good things, but have we seen an overall improvement in clinical outcomes, patient experience of care, total cost of care? We know all too well that proximate outcomes may not lead to the ultimate outcomes we need.

It is time to pull the plug on this experiment, it is hurting our patients, it is hurting America.

It is time to follow the data demonstrating the worth of effective primary care.

We need the resources to pursue our professional obligations for our patients.

Gordon

[Guest guest]

And i thought the wall of shame was papered in all those med school rejection letters i got years agoI mostly agree and I have used many of these techniquesIn Maine Blue Cross will not speak to you if you are on a speaker phone with the patient " It is our policy " they say NOT to speak to you when the patietn can hear them , as a has also experienced .Doesn't that just take the prize for arrogance!

Also though is it is so difficult to be a patietn, It is really awful, that joining with them is a delicate art They may " appreciate " what we explain to them but many can't see or hear or read

I know you know this

They are in pain and have 3 part time jobs no land line a broken down car I know you know thisI have involved pateitns frequently but still it is an uphill battle Handing them a phone number and putting words in their mouth and still they take no action They have cars that cost 100.00 and you know ar e in pain or afraid etc etc Have 3 part time jobs a crappy husband kids in trouble etc etc

I know you know all this I did a survey a year or so ago asking patients what they thought a doc should make they were quite fair. I think the vast majority of people would not begrudge us better conditions especially if IF it immediately translated into better access and care for them But most patients are passive allies becasue they have their own troubles.

nevertheless I agree we should persistIt is somewhat fruitful to engage patietn in getting what they need for themIt is not very helpful to ask them to be politically active though

The public is mostly unaware of how amazingly complex, time

consuming, and trivial our work is when we're not in the room with

them.

To help make the point, it is helpful to have on hand the

policy documents you receive from insurers.

I love the 8.5x14 inch double sided documents from BCBS I

used to receive in Rochester

NY telling me in 9pt type all the

variations for co-payments. The co-pay varied based on the type of visit,

the employer contract, and the type of plan(s) chosen by the employer.

I imagine a wall in each of our offices (waiting room wall

would be good) that is papered over by the documentation requirements for prior

authorization, the documentation requirements for CPT codes, the auto-rejected

claims based on down-coding engines, the rejected claims. I imagine a

collage showing how many times you have to re-submit to get paid a fraction,

and what happens when a patient has Medicare primary and a supplemental

insurance. We could paper an entirely different wall with all the

formularies from the different insurers (make sure to point out that they get

legal kickbacks from the pharmaceutical industry to steer their " members "

to certain drugs.

Some other techniques I love:

Have the patient sit in the

room with you as you try to obtain prior authorization. Make sure to

do it on a speakerphone. One of my favorite anecdotes is a doc who asks

the patient " Do you have a cell phone? " The doc then

borrows the pt's cell to call the insurer & says " come get

me in the next room when you get through the 'on hold' line. "

You could create a laminated sheet that tells patients how to " press

3 for … " etc.

Ask your patients to call the

insurer to ask why a claim wasn't paid and come back with the

answer.

Have a separate phone in the

waiting room and ask your patients to verify their insurance status and

check on the co-payment for every visit (like we're supposed to do).

Give your patient their list of

recommended prescriptions and have them try to find on the web or phone if

these meds are covered and at what co-pay and at what pharmacy.

As I type this list I sit back and think " gosh, this

is starting to seem cruel. " And then I think " IT IS

CRUEL!!!!! " How can we keep up with this nonsense!?!? The

public must be made aware that this is way beyond " annoying paperwork "

and into the land of " we can't even get to our work for you because

we're drowning in this insanity! "

We've had 20+ years of the experiment in managing " care "

through price control, prior authorizations, formularies, case management,

disease management. Many executives hold up graphs showing improved

generic prescribing rates, improved cost of care of high illness burden

patients, reduced A1c burden for patients with diabetes. These are good

things, but have we seen an overall improvement in clinical outcomes, patient

experience of care, total cost of care? We know all too well that

proximate outcomes may not lead to the ultimate outcomes we need.

It is time to pull the plug on this experiment, it is

hurting our patients, it is hurting America.

It is time to follow the data demonstrating the worth of

effective primary care.

We need the resources to pursue our professional obligations

for our patients.

Gordon

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