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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