Getting Your Doctor to Act !
When Cathy, a 60-year-old San Diego woman, came down with a nasty
case of the flu last Christmas Day, she was disappointed to have to leave a family
gathering and crash in her bedroom but figured she was just one of many unhappy
souls who were part of a huge flu epidemic in Southern California that winter.
Things soon turned much more serious. Several
days later she turned frighteningly lethargic and her husband rushed her to the emergency
room, where she was diagnosed with pneumonia, plus another relatively rare complication
a neurological disorder called Guillain-Barre syndrome.
The latter disease, which can follow an infection and
cause varying degrees of paralysis, was diagnosed by the hospital's on-call neurologist.
After she was sent back home to recuperate, Cathy's HMO assigned her primary care doctor
to oversee her recovery. The neurologist who had been so helpful in the hospital was
nowhere to be found.
If she was diagnosed with a
neurological disorder, shouldn't a specialist have followed up?
Maybe so, but Cathy and her husband found it
difficult to question their primary care doctor's judgment on the matter. He seemed
interested and capable, but he also ran short of patience if they asked too many
questions. Cathy and her husband, old enough to be used to a medical system in which the
doctor shouldn't be questioned, thought they'd anger the doctor they depended on so much
if they asked for a referral to a neurologist.
The San Diego couple's situation is common the
Center for Patient Advocacy in Washington, D.C. says referral problems are the number one
complaint they hear from consumers. Ever since managed care organizations such as HMOs
turned to the "gatekeeper" system entrusting a single primary care doctor
to oversee patients' overall health care consumers have had to get used to getting
"permission" to see specialists to whom they once had easy access.
There's actually some solid medical reasoning behind
having a primary care or family doctor oversee a person's health care (a primary care
doctor is usually an internist, who is a generalist doctor with training in many different
areas). It allows the patient and doctor to develop a long-term relationship and gives the
physician a chance to see the big picture, which can reduce the chance of problems such as
prescribing conflicting medications.
On the other hand, many people are uncomfortable with
the financial incentives set up around the gatekeeper approach
in some circumstances, family doctors may receive more money the fewer
specialist referrals they give out.
changes in the doctor-patient relationship have left everyone on shaky footing but
the people feeling most vulnerable are patients. Many people, like Cathy, are left
uncertain how to get what they want from their primary care doctor without alienating him.
"Your own personal health and whether you live or die is quite emotional," Cathy
says. "It's not like taking a pair of pants back to the department store."
Asked how such situations can be finessed, various
consumer advocates all suggest that patients find ways to play a new, more assertive role.
"Talk to your doctor and ask questions,"
says Lorie Slass, communications director of Families USA. "Your relationship with
your primary care doctor should be open and trusting."
Think of the relationship in a new way, as a
partnership, says Dr. Vincent Riccardi, a Los Angeles physician who runs a consumer-help
company called American
Medical Consumers. "If you can say it in the right way, I think you can get your
doctor to help you," Riccardi says. He recommends that patients use honey instead of
vinegar. "Just say, 'Hey, doc, I need some help.' Tap into the reason why they went
into medicine in the first place, to help people."
"Explain your needs to the physician in a way
that communicates what your need is without being aggressive about it," suggests Jim
Giuffre, senior vice president of Healthwise, a not-for-profit group that educates health care consumers.
"Ask the physician their opinion of the pros and cons of a referral, and what
questions you should ask if you see a specialist."
One easy way to rile a physician is to accuse him of
refusing a referral because it would take money out of his pocket. "There's a right
way of approaching it and a wrong way," says Giuffre. "It's a matter of mutual
respect. You wouldn't want the doctor to assume the worst of you, so don't assume the
worst of him."
Take into consideration the fact that doctors these
days are pressured for time, suggests Alan J. Steinberg, a California internist and author
of "The Insider's Guide to HMOs." Make your case succinctly and without vitriol,
and you have a better chance of getting your doctor's support. It also helps if you have
done some research ahead of time and can offer some evidence why a referral is really
necessary. "I don't mind if someone questions my judgment, the important thing is
that we figure out what's wrong," Steinberg says.
Such discussion, while difficult, may well strengthen
your relationship with your doctor. Like a marriage, the relationship depends on good
communication and trust built up over time. It's worth the investment to have a medical
professional who not only knows your history, but is willing to go to bat for you with the
bureaucrats in the health plan.
But if the relationship isn't working out, don't
hesitate to bail out. Ask friends and family to suggest another primary care doctor. And,
if you want to pursue a denied specialist referral, be sure to check your health plan
handbook for the appeals process, which may involve calling or writing to a medical
director or committee. In some states, the health plan must also provide an external
review process for disputes.
If time is of the essence and the illness is serious, dont bother waiting
for the outcome of appeals just find a specialist and pay for it yourself.
- You can always battle the health
plan for reimbursement later.
Ultimately, this issue should let up as health plans
move away from the gatekeeper approach, which has been generally unpopular with patients.
"Many plans have bypassed this idea of the gatekeeper," notes Giuffre. "But
as long as such barriers still exist, patients need to be taking the reins!"
Our Rights Return