As my regular readers know, I'm not a big fan of our current health care system. Our bloated, industry-driven system manages to deliver less effective care at a higher cost than most other industrialized nations. The system is Byzantine, unnavigable, and dangerous, and is kept that way in the name of the Holy Market. But health care can benefit from practices that are decidedly un-capitalist, at least in the Milton Friendman or Ron Paul sense.
Like aviation, health care must apply risky and expensive practices to large numbers of people in dangerous situations. This process is made safer by certain sorts of standardization, such as checklists. Data suggest we would also benefit from developing widely applied, evidence-based best practice guidelines, and from increasing the use and interoperability of electronic health systems. But that's not how we do things here.
Our culture is strongly biased against centralized anything, which is often a useful instinct. But in health care, the market does not necessarily drive best practices, but most profitable ones. One of the worst hybrids of the ultra-free market ideal and the more communitarian ideal is the HMO. It's not that the idea is inherently bad, but its implementation has often been problematic.
An HMO is an agreement between a patient, a physician, and an HMO. The patient pays a premium to the HMO, and co-pays to doctors and other providers. These fees are usually significantly lower than in other types of plans. The HMO assigns them to a primary care physician and agrees to pay for care the PCP recommends, within the guidelines of the plan. This puts the PCP in the position of "gatekeeper" for more complex medical care. The doctor is often payed less to care for HMO patients, but in exchange the HMO sends them patients and keeps them busy. But this system is often a loss for both the doctor and the patient.
A common way doctors get paid by HMOs is "capitation", that is, getting paid per head. An HMO will offer a doctor x dollars per month per patient. This reduces the incentive for the doctor to provide unnecessary but potentially profitable care. In fact the incentive is exactly the opposite: the more patients the doctor enrolls, and the fewer services she provides, the more she and the HMO will profit. Basically, HMOs are designed (in their classic form) to give the appearance of providing efficient low cost care, while actually providing inefficient, low cost care that can be minimalist at best.
Is it ethical or not for a primary care physician to make a referral for a patient he/she has never seen?
Recently I found myself out of town at the same time I was between PCPs. My original PCP was at a facility that was closed with less than a week's notice.
Shortly thereafter, I finally found a civilian physician willing to take a Tricare Prime patient and faxed the papers to Tricare. I was told that any request received before the 20th of the month would take effect on the 1st of the next month... if approved.
During this window period, I developed stomach pain and a fever. The next day I tried to get a referral from my insurance for a visit to an urgent care clinic. I was told this could not happen without a referral from my PCP. At the time, I thought I did not have one, but was informed that my new PCP became effective upon receipt of the fax -- April 17.
My new PCP refused to give a referral, as I expected because she'd never seen me.
Anyway... I went to an ER (no referral required) and was admitted for surgery for [a life-threatening surgical condition]. The surgeon questioned me about the surroundings I'd be released to after surgery and recommended certain home health accommodations.
Since home health also required a PCP referral, I paid for them out-of-pocket. I won't try to get reimbursed for these services because they really were minimal, but I'm quite angry about the whole thing. At one point, a Tricare Prime representative told me that I would also have to pay out of pocket for the follow-up appt. with the surgeon. The surgeon's office subsequently assured me that was covered under his fee for the surgery... but it still made me angry.
It seems to me that IF a PCP is required for referrals, that Tricare Prime cannot allow a situation to occur where one would be without a PCP and that they cannot require a physician to act unethically.
That's why I would like an unbiased view of the ethics of a physician signing off on a referral without ever having seen the patient.
Thank you for taking the time to read my email.
Fascinating. And not atypical. It seems that even the HMO employee didn't understand all of the intricacies (such as the surgeon's fee covering follow up appointments). It wouldn't surprise me if some of the services she needed were actually covered. But that wasn't her question. She was very tolerant of her HMO, and has a question about ethics.