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Is This Normal?

This is a story about consumer choice using publicly available information. Unfortunately, it is also about the power of suggestion as used by an incumbent provider organization.

The friend who sent me this note is a research fellow at one of the Boston teaching hospitals, so I guess he is more likely than most to do the kind of research he summarizes. Most people would have taken the referral advice offered without question. If they ever did ask to see a different doctor, most would never get past the “need” for asking for “special permission.”

Hi Paul,

I had a strange encounter, and I was wondering if you could tell me if this is normal.

A few months ago my primary care physician recommended I see dermatology for my eczema. His clinic recommended the names of two dermatologists within the same health care system. I looked up both dermatologist on healthgrades.com and found that their patients had given them luke-warm reviews. (There were many reviews, so this wasn’t a sampling problem). Also, I have been reading the medical literature about eczema, and knew there were a lot of recent advances, so I wanted somebody who had published and was familiar with the research.

I found another dermatologist, Dr. Caroline Kim. Her patients loved her (according to healthgrades.com), she had published articles in dermatology research (from scholar.google.com), and she trained at top institutions: Harvard Medical School and MGH. I made an appointment with her.

I called my PCP and asked for a referral. The receptionist told me Dr. Kim was “out of network” and they would have to ask my PCP for special permission. I thought this was odd because I had Blue Cross PPO insurance (not HMO), so as far as I knew, there was no “out of network”.

A month later, my referral had not been sent. I called my PCP again, and asked for them to send it. After I gave her the name and phone number of the dermatologist, this was the conversation.

Receptionist: I am sorry, that is out of network. We will have to check with Dr. X.

Me: What does “out of network” mean? I thought I had PPO insurance.

Receptionist: You won’t get the best care if you go out of network.

Me: Is this a [health care system] policy?

Receptionist: We might not know what medications you are prescribed if you go out of network. Your medical records might not get transferred back to our office.

Me: Is this a [heath care system] policy?

Receptionist: Yes.

A week later I had my referral.

It seems like this health care system is using an insurance term — “out of network” — to trick patients into going to specialists that work for the same company. Am I wrong?

Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that under Massachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.

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12 replies »

  1. Health care professionals have become very profit minded these days.The medical charges have become so high that it becomes difficult for a common man to meet the demands of these health care professionals in case of an emergency.

  2. I’m baffled like Spike by why the writer sought and waited for a referral if s/he was in a PPO. In New York, PPOs can’t require referrals. Are they different in MA? Was this a POS plan (Point of Service, not Piece of…you know)?

  3. I’m baffled like Spike by why the writer sought and waited for a referral if s/he was in a PPO. In New York, PPOs can’t require referrals. Are they different in MA? Was this a POS plan (Point of Service, not Piece of…you know)?

  4. I’d imagine this will happen more often as EMRs and other electronic records unite docs across a provider (and don’t at all talk to the docs at other provider groups).
    Vertical integration seems the end-game of the ACO movement. This seems counter to a “consumer choice” or open application model where consumers could stitch together their “best of breed” physicians across multiple health entities.

  5. This letter typifies what is wrong with health care these days, if people are flocking to the internet for referral sources, and not the best source: patients who have used a provider! And this person works in the health care system and cannot ask a few people if they or someone they know have used a provider in the specialty of need here, and been satisfied with the care received?
    I don’t get the point of this post, Mr Levy! Is it to embarass the limited vision of this writer’s provider, the insurance system in general, or, the futility of access to care for people, especially those who operate in the system in the first place.
    I am going to make a comment that is going to annoy people, like this is a revelation for those who read my comments, but it needs to be said. People who work in the health care industry do have advantages over those who do not, and one of the biggest is accessing information to whom is the better provider to try to see, and more often, if you drop a name when calling for an appointment, you’ll probably get in. Not that this is unique to health care, as it isn’t, but in the end, we take care of our own, and it may be wrong, but, it is the reality it is.
    So, where did this writer fail? To me, tolerating the wait for the referral. His provider equally failed in dragging his/her heels. As someone above said, time is a valuable resource, and can literally make or break the chance for healing and recovery. And in the end, the way I practice, you cannot play favorites, for the most part. You are asked to make a referral, get it done! Or, have someone you rely on who is responsible and effective speak for you!
    Like, in any other field of service that is supposed to be responsible and effective. Gee, like any business or service provider that is moral and ethical?!
    Or, is that last sentence an oxymoron?

  6. Seems like PPOs would have “in network” and “out of network” but not require a referral. I’m mystified why someone covered on a PPO would need a referral from their PCP in the first place?
    It sounds like they’re out of the PCP’s clinical network and it has nothing to do with the insurance coverage.

  7. I can add some information here on the accuracy on online physician ratings and referrals from a couple months ago. I’ll also give a link to my conversation with the AMA and together we put together quite a bit of information and tons of errors as I had many doctors write in and comment on the links about dead doctors, retired doctors and inaccurate specialties along with one listing of someone who never practiced medicine.
    http://ducknetweb.blogspot.com/2010/09/healthgrades-and-other-md-rating-and.html
    One more new service opens up and errors in the data base already with using information not updated. The example shows a doctor with a 5 star rating that has admitted to Medicare fraud for the second time.
    http://ducknetweb.blogspot.com/2010/11/avvo-physician-rating-service-cant-get.html
    Here’s my conversation with the AMA from their website.
    http://www.ama-assn.org/amednews/2010/10/18/bica1018.htm

  8. Astonishing that this kind of behavior isn’t illegal given the number of regulations covering referrals. Or is it? If not, it should be.

  9. i have heard of this in our area, so it must be fairly common. To be fair, it is often difficult to get information when studies are done out of the system. If I need to have a patient see a cardiologist before a procedure, or if they have already seen one, it is often difficult to acquire the results without having the patient hand carry them. With many of my patients, that also fails. Anything done in system I can access on the computer.
    Steve

  10. Is this normal? Who knows but it surely is typical. You waited a month for a referral! What if this had been truly an acute situation requiring immediate attention. Yes the poorly trained “receptionists” often control access to physicians and to referrals. They are given prepared scripts by their employers, the health system.
    For fun try getting a referral without insurance. Its a game more and more Americans get to play.

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