You May Not Be Getting The Tests or the Specialty Referral You Need for Your Medical Condition

If you take a look at guidelines for your chronic medical condition like diabetes or heart disease. Some of you may find that you’re not getting all of the lab tests that you need.

And some of you may be going to your doctor repeatedly for a condition. And even though you’re not getting any better your doctor isn’t referring you to a specialist.

Beware that some insurance companies pay doctors or even decide whether a doctor can be in their network by whether or not the doctor holds down the amount of money he spends on tests and specialty referrals. In some financial arrangements, doctors try to hold down those testing and referral numbers so that they can get the full payment offered by the managed care organization. The MCO withholds a certain portion of the doctor’s payment and then the doctor’s bonus at the end of the year depends upon how well he holds down costs on testing and referrals.

Although it’s unfair to patients for their doctors to have these divided loyalties these are the facts in medicine today.

Your doctor is likely to have patients in several different insurance plans. For example, in a contract with one company for that group of patients he might get paid a set fee each time they come in for an office visit. In a contract with another company for that group of patients he gets paid a certain amount per month for each of those patients, no matter how many office visits they need. And in a contract was still another company, he also gets paid a certain amount for each of those patients per month, but lab fees, x-rays, and referral fees to specialists have to be paid by him. The insurance plan pays that way on purpose to encourage the doctor to order only what’s required.

What doesn’t feel fair is that you the patient don’t know what the doctor’s financial arrangement is for you.

It seems only fair that doctors should disclose to you what their financial arrangements are with your insurance company so that you can make decisions wisely by knowing all the facts. Or maybe your insurance company should disclose that information to you.

Make sure that you know what test you need for your chronic condition and make sure that you’re getting them. And if you’re seeing your doctor and are not getting better, insist that he refers you to a specialist.

“Many managed care organizations include financial incentives for primary care physicians. Incentives that depend on limiting referrals or on greater productivity apply selective pressure to physicians in ways that are believed to compromise care”1

“A spectrum of methods exist for calculating physician bonus payments. Each physician’s referral cost may be tracked individually with the end of year bonus depending on each physician’s own cost to the IPA in specialty and ancillary referrals.”2

“Primary care gate keeping in which the goal of the primary care physician is to reduce patient referrals specialist and thereby reduce cost is not an adequate system in which to practice medicine. The practice of primary care is troubled. Most managed care organizations use primary care physicians as gatekeepers, controlling access to specialty care.”3

“Many believe physicians are still placed in situations that create potential conflicts of interest. Patients currently have little knowledge of these implicit rationing methods that can affect access and the types of care they receive.”4

Studies, Footnotes and Resources:

  1. Grumbach, Kevin, Dennis Osmond, Karen Vranizan, Deborah Jaffe, and Andrew B. Bindman. “Primary Care Physicians’ Experience of Financial Incentives in Managed-Care Systems.” New England Journal of Medicine 339 (1998): 1516-1521.
  2. Bodenheimer, Thomas S., and Kevin Grumbach. “Capitation or Decapitation: Keeping Your Head in Changing Times.” Journal of the American Medical Association 276(13) (1996): 1025-1031
  3. Bodenheimer, Thomas S., and Bernard Lo, and Lawerence Casalino. “Primary Care Physicians Should Be Coordinators, Not Gatekeepers.” Journal of the American Medical Association 281(21) (1999): 2045-2049.
  4. Cleary, Paul D. and Susan Edgman-Levitan. “Health Care Quality: Incorporating Consumer Perspectives.” Journal of the American Medical Association 278(19) (1997): 1608-1612.