Getting Your Doctor to Act !

J Green



      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
      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.

      These huge 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, don’t 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!"



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