Wall of shame documents

[Guest guest]

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