I received one of those politely worded letters from a major insurance company recently informing me of how it thought I was doing caring for one of my patients. It includes warm language such as “We value our relationship with you,” though their medical director who signed this letter has never made an effort to develop a personal relationship with me. The letter goes on to say “[This company] continuously seeks ways to support your efforts to provide the best possible care for your patients.” Best I can figure out, this company must have been hired to perform a chronic disease oversight function by Medicaid, which is this patient’s coverage.
These letters are typically worded claiming that the insurance company is on my side to help me close care “gaps” for my patient with diabetes. The company bases its Big Brother feedback on its electronic claims data, which this letter claims has “… extensive data assets and analytic capabilities, we are able to provide you with data that can give you important patient-specific information.” There are at least three problems with this letter and the company’s attitude.
The first problem is this patient just started to come to our clinic within the last two months. He may have just qualified for Medicaid or perhaps he recently transferred his care to our clinic from another physician. The insurance company’s computers are no help to me seeking out information outside my own clinic walls. (Also, I’ve never actually seen this patient, two of my colleagues did. My name must have been assigned to him on his Medicaid card.) The company’s assumption that two months is enough time to address all relevant chronic disease concerns is absurd. Chronic disease care is always a collaboration with patients, who often don’t want to do things their physicians would like them to do. Sometimes it takes multiple visits to get patients caught up with recommended treatment, if ever in some cases.
The second problem is that this letter makes it clear I’m supposed to take my time searching out his records to answer their letter. I dislike unfunded mandates. Insurance companies and health benefit consultants have convinced employers that disease management companies should be paid for “care oversight,” but they’re not willing to pay me an extra dime for my time to deal with their paperwork. And don’t think my nurses have time do this. They work their butts off as well and aren’t sitting around looking for something to do.
I went ahead and looked up his information. Here are the four “Health Opportunities” this company identified:
“… [your patient] may not have had two A1C lab tests in the past year.” He just started coming to our clinic.
“… [your patient] may not have had an LDL lab test in the past year.” We ordered one the first time we saw him and it’s fine.
“… [your patient] may not have had a triglyceride test in the past year.” We ordered one the first time we saw him and it’s fine (it’s part of the same cholesterol panel the LDL is part of).
“Our records suggest that your patient may have a history of diabetes and may not have had a screening for diabetic retinopathy in the past year.” I can’t comment as specifically on this issue (I’m writing this without his paper chart in front of me). This retina screening service doesn’t appear in our electronic record summary. I don’t know if this test was ordered but the patient either hasn’t had an appointment yet, or one was made and he never showed up, or if he had one recently with an eye doctor outside our system. Their “extensive data assets and analytic capabilities” are not powerful enough to actually help me check his eye screening status in outside facilities.
The third problem is that the letter portrayed these tests as “cost-saving opportunities.” This statement shows a profound ignorance of basic medical economic realities. Testing and treating high cholesterol (LDL) doesn’t save money and is extraordinarily expensive for low-risk patients. There is no evidence treating isolated high triglycerides improves any outcomes patients care about. Screening for diabetic retinopathy (eye disease) doesn’t save money and is extraordinarily expensive for low-risk patients. There is no evidence any specific scheduled pattern of A1C testing saves money, nor does adding more medicines to lower A1C levels save money.
This letter was signed by the national medical director for this insurance company. I wonder if he’s really ignorant of medical-economic realities, or if he just sold his soul to his employer and those who hired it (large corporations and/or Medicaid plan administrators), and he would rather sign an erroneous letter than confront his masters with difficult truths.
This company put little thought and effort into this silly attempt to improve quality of care, but this useless letter allows them to go back to the companies that hired the insurance company with the box checked that they provided chronic disease management. This is a prime example of the excessive and wasteful administrative overhead of U.S. healthcare. I will not waste another minute of my valuable time filling out their form and mailing it back to them. I will give it the attention it deserves by tossing it in the shredder box.
Thank you for that wonderful review of unwanted letters from insurance companies. I receive about 10 of these letters every week. Everything you said was correct. My problem is I have patients who want to get that lab work done every month but they refuse to change their diet or exercise or even take a medication for their elevated lipids. I love the diabetic eye exam because before they leave they have spent way to much money. I usualy fill them out fax them back and on the patient’s next visit give it to them.
Dr Young:
I am constantly baffled by contradictions to the perceptions we have been led to hold as truths. And it isn’t helped by the seemingly endless supply of course reversals on drug efficacies and other widely-held perceptions of what should/shouldn’t be done for given maladies or what should/shouldn’t be done to effect proper prevention of disease. Having read much of what you’ve written, I am mystified as to what really does work and what constitutes both quality and cost-effective patient care. The more I read, the more I appreciate how much money is being wasted on the excesses that improve the lots of everyone but patients. And patient certainly do not escape the blame when, as Dr Updike mentions, they fail to adhere to the more common sense lifestyles and treatment courses that would eliminate so many problem. An example that constantly amazes me is reading about obese, diabetic patients who take off the fat and become former diabetics needing much less management.Unfortunately, too many lap-band, sleeve and gastric bypass surgeons are telling us that can be easily done with the knife instead of the important lifestyle modifications.
So what are we to make of LDL levels and elevated triglycerides? What about AIC – is it a good marker for diabetes? I wonder how many tests are pure wastes of time? Do I contemplate telling my family physician to skip monitoring cholesterol levels that have slowly dropped from what might have been viewed as potentially catastrophic to acceptable, in conjunction with monitoring and treating blood pressure? What is right? What is wrong?
I can only guess what the offset might be if we redirected much of the money being spent on way too much of everything else – to basic common sense doctor-patient face times where the doctor knows the patient, knows through timeless diagnostic skills just what tests and treatments are needed and has the time to employ those skills. Economically, the waste of money is measurable by many standards, but – the waste of the time that a primary care physician could employ to do better for the patient will be immeasurable until some reasonable common-sense method of reimbursing that physician for those time skills can be quantified against the other cost standards that will undoubtedly demonstrate that less can truly be more. In 30 years, I have have watched in mute amazement as the bureaucratic paper logjams have worsened and have taken up too much valuable time, just so some insurance company or some cost management company can crow about protocols that do little to improve the quality or cost-effectiveness of care.
Chris,
You ask complex questions with no black-and-white answers. The long answer depends on how much you want to devote your resources to these pursuits vs. other things that bring health and happiness to your life.
The short answer is worry about the LDL if you’re middle-aged or older (but not if you’re young-with rare exception), don’t worry about triglycerides (there are a few exceptions), don’t be afraid to spread out LDL checks if they’ve been good and stable, and if your diabetic, worry about the A1C a little, but worry about your blood pressure more.
Hope that helps,
Richard
Yet another situation where one has to wonder who in the world the AAFP thinks they are representing.
In spite of overwhelming evidence that P4P programs don’t improve care and impose an enormous administrative burden on physicians, the leadership of the AAFP is lobbying agressively for their inclusion in payment reform. I really don’t get it!
Robert:
As Dr Young knows, I have been devoting a good deal of time to increasing awareness about the wasteful and inefficient health care system that has been fashioned. Like many other endeavors, it’s really a matter of holding something unpleasant right under peoples’ noses long enough until notice is taken. I’ve watched our system devolve over 30 years of physician advisory work and the devolution is picking up speed as we’e increasingly ignored the crisis long brewing in our critical primary care medicine services. I write and blog about this, and have attempted to entice and badger the various media to give this some good press – to say this has been frustrating is to make an understatement. This story appears to lack the sexiness of other medical glitz. Evidently, in healthcare as in so many other pursuits, we cling tenaciously to the time-honored practice of waiting to panic until we’re about to go off the cliff. At what point in time will our increasingly exhausted supply of primary care physicians tell us the wheels are off?
I have been talking to influential people deeply committed to reformation and restoration of respect for the cognitive aspects of primary care, both in terms of appropriate payment for this broad and critical area of care, and in elevating a primary care career path in the eyes of aspiring next generation physicians. I had been hoping for action on the part of AAFP – definitive action – spurred by the calls of the New Jersey and Florida academies to scuttle the AAFP’s participation in the RUC. I had been slowly forming an uneasy opinion that AAFP was like so many other fuddy-duddy “committee-afflicted” organizations that prefer to move at a snail’s pace because it ruffles fewer feathers. But I had slowly arrived at a conclusion that maybe AAFP was responding to the legions of family physicians out there who, as one of my favorite family practice docs says, are “lovers, not fighters”. The one question that I think freezes every truly practice-focused primary care physician is “if we boot the existing system, where do we go from there?” I know from previous conversations with Dr Young and other PCPs that this is a question needing answers.
So maybe we’ve seen the AAFP put a toe in the sand and draw a line. Maybe 3/1/12 is not so far off. But between now and then, the legions of family practice docs out there need to be informed about the game ante and what the stakes are. If primary care medicine is headed for a showdown at high noon, then the primary care doctors should be on board.