I spent most of my evening at the urgent care clinic. My little guy’s asthma had been getting bad and we wanted to avoid the overnight ER visit for a multitude of reasons. The inhalers and nebulizer treatments had been creating sixty to ninety minute long bubbles of good breathing and then the therapeutic period would end. The primary objective tonight was to get a prescription for liquid steroids and then watch and wait after another round of breathing treatments. We were released and he fell asleep before we were out of the parking lot.
Before we left the clinic, the doctor gave me a brief list of instructions — get the prescription, make sure he is propped up while sleeping, and if he is having significant problems overnight, take him to the regional pediatric specialty hospital ER. This specific recommendation caught my ears. The urgent care clinic is staffed by the same provider group that staffs that particular ER.
We’ve taken my son to the ER a couple of times for breathing problems. We have gone to the pediatric specialty hospital. We have gone to the community hospital. The claim always comes back as a Level 3 ER visit with very similar sets of procedure codes. The only difference on the explanation of benefits and the bill is the contract rate for a basic Level 3 ER visit and basic asthma treatment. The regional specialty hospital gets two to three times as much from my insurance than the community hospital. Our experience had been there was minimal difference in the time it took my son to resume breathing reasonably well on his own at either location.
I only know this because I play with claims data and fee schedules on a daily basis so I have an absurd attention to my EOBs. If my son is in trouble overnight, the most probable case scenario will have me take him to the community hospital as the care is fine there. If he is in extreme trouble/turning blue, we’ll head to the specialty hospital, but the 90% scenario if we leave the house is to go to the community general hospital.
Most parents in my shoes would not even think through the choice of the two hospitals. They would not have the knowledge nor the readily available data to make this type of choice, nor would they know that the referring doc works for the same company that staffs the specialty ER.
My question, and this is an honest question, is simple — does a doctor who makes a referral have any obligations to the patient beyond not sending them to grossly incorrect providers (ie sending someone to a neurologist for a broken ankle)? Is there a reasonable man standard or higher for referrals or are conflicts of interests fully allowed?
Baud
Poor fella.
Luthe
I think it should be like a doctor prescribing a generic vs. name brand: if the generic (your average Dr. Joe) is good enough, send the patient to him; if only name brand will do (Dr. FancyCare), refer them to her. Sending a patient to another doctor in-group just for the money sounds like a kickback scheme to me.
lahke
Sorry to hear about your son’s issues, Richard. Is pediatric asthma more prevalent than it used to be? Or do I just know more people for whom it’s a problem?
Renie
Here on Long Island NY we’ve had a proliferation of ProHealth clinics sprouting up. Some of them have bought out doctor practices and the doctors then work at ProHealth. But the prior relaxed individual care from the formerly private doctors is now gone at ProHealth (even though it is the same person).
In your opinion, is this the wave of the future for medical care now? I wonder who owns ProHealth and what is driving the operation.
Mike in NC
I have asthma and for many years bought OTC inhalers until they were taken off the market to protect the freaking ozone layer. Now I need to request prescription types that are both much less effective and cost twice as much.
SRW1
Patients don’t have the knowledge. Physicians have a conflict of interest (and presumably pressure from their provider colleagues). The only other party with the possible knowledge and access to data indicating that channeling of referrals to higher cost options for reasons of profiting from it is going on are insurance companies. I’d see a role for insurance companies in this.
Hopefully your little fellow doesn’t need you making any decision where to go tonight.
Mike J
Rephrase the question: does the doctor owe more loyalty to the megacorp that the patient uses or the megacorp that signs his paycheck?
If it’s going to cost the patient more out of pocket the doc owes it to her to tell her. Ceteris paribus, he owes the people who own him,
Big R
Short answer is no.
JCJ
Certainly employed doctors are told by their employers where to refer patients. That would mean that if the urgent care doc is employed by the same entity as the specialty ER group he could be threatened with penalties (less pay) if it was known that he was referring to a different group. As long as the care is equivalent most docs won’t worry, but patients are often referred to a facility much further away which in some cases introduces an unnecessary burden. My example would be a patient could be referred to me for a course of radiation over twenty treatments where the patient would have a ten minute drive but instead is referred to a different facility which is a forty minute drive away for a course of radiation which lasts for 33 treatments. The two courses of treatments are equal as far as efficacy, but obviously there is a large difference in cost in terms of both time and money. A medical oncologist friend from a different system told me about a meeting he went to where radiation for prostate cancer was presented with 28 treatments instead of 40 or 43. He asked what I thought. I told him my group has been doing it that way for several years (at least eight) – the very large group he usually refers to (and is told to refer to by his employer) never does the shorter course of treatment despite the fact that there is zero evidence that the longer course is in any way better.
Don’t know if that helps address your question. I guess it could be summarized to – No, referring doctors don’t take cost or patient convenience into account.
benw
The health care and insurance nexus is so byzantine, I doubt most doctors have enough information to make a fully informed referral choice. Doctors don’t know the details of a patient’s insurance plan, for example, to know which referred provider might cost a lot more than another, given the same level of care. And I hope your son feels better.
Prescott Cactus
Richard,
First I hope your child is on the upswing. I think doctors should be required to notify you of conflicts or potential conflicts of interest. My Doc’s office is in a building that has a blood draw place that is fed patients by all MD’s there. I don’t know if it would be cheaper to hit a “real” blood lab, but I should find out. Kind of awkward asking, Hey Doc, you a partial owner of the lab?
Or even “Nice tan, did you get that during your weekend in Malibu at the Smith Kline Glaxo meeting where they pushed the Advair Diskus Inhaler that you just happened to give me script for ?”. They should be forced to wear emblems like NASCAR drivers. As should politicians.
@lahke:
lahke,
I’m unsure of prevalence, but when I started my asthma adventures (20 + years ago) I was told that if you had it as a youth, often it would diminish w/ puberty and be less serious with age. Also the other main periods for starting asthma were around age 30 and 50. My family history nailed this scenario perfectly. Asthma seems to run in families. Gramps, Mom, her brother and myself.
I was diagnosed at 29 and was told asthma would be lesser than if I got it when I was 50. Again this bore out in my family history as my Gramps was in sad shape from his 50’s to his departure at 78, moving several times to find the right climate.
My triggers are cold / wet or hot / humid. I tried the desert and have, thank FSM, am off all meds. Life changing in that I no longer need to even carry a rescue inhaler.
Not sure if that pediatric, age 30 , age 50 stuff is scientifically documented but the pulmo doc I had was a miracle worker.
Peace to all
BubbaDave
So, this may be naive, but… are you sure that doctor knows it’s the same corporate structure? I know I’ve had to explain a few times to employees of one of our sister companies that we’re owned by the same $BIGCORP that they are and they really ought to be working with me.
I could see an environment where the doctor has been told “We generally refer pediatric patients to Our Lady of Specialist Income” and assumed it was because specialist = better. Since you’re saying minimal difference, that means patients aren’t getting worse care, so they’re unlikely to tell the doctor “That pit you referred us to was horrible– what were you thinking?” As far as the doctor is concerned, referring to OLOSI is convenient and in case the patient ends up in severe complications may be where the kid would be transferred anyway.
Or maybe I’m too optimistic. I know in Virginia 20 years ago my mom was stunned to learn that a competing practice had a new machine and doctors had a quota of tests they had to order per month. That was a pediatric practice, and the procedure (throat swabs? something else?) was uncomfortable/painful enough that a small child burst out crying in my mom’s office when she diagnosed the kid with an ear infection because the kid was afraid my mom was going to do that (uncomfortable and unnecessary) test. (The flip side is the parent switched to the practice my mom worked for based largely on the fact that there were fewer tests. So EvilDocsInc made more money per patient, but lost patients as well.)
MomSense
I hope your son feels better and that you can all get some good rest. I went through this with one of my boys. It was exhausting and terrifying and very stressful. Sending healthy wishes to your son.
delk
Heh, as I was reading this Blue Cross sent me an EOB for some prescriptions I just picked up.
So far this year Blue Cross has been billed 42,933.97 and the month is not over yet!
Scamp Dog
@Prescott Cactus: I was in the “got better during puberty” group, and I’m so grateful for that. As a kid I spent many nights struggling to breathe and needing to go to the emergency room. There’s something particularly awful about having to struggle to inhale, to the point where you have to make a conscious effort to work your muscles.
I also remember the first time I was able to run and got tired instead of choking up. I had never been able to do that before. Wait, I’m breathing heavily, with lots of air going in and out? This is great! I don’t know that anyone has ever been so happy to be tired as I was then. Actually, probably other recovering asthmatics, come to think of it.
Richard, I hope your son is breathing better soon.
rikyrah
hope your little guy feels better Mayhew
benw
@delk: Now THAT’S how you hit the out-of-pocket max, baby!
Liam Yore
ER Doc here.
The Stark anti-kickback law prevents a hospital from paying (directly or even in very indirect quid pro quo) for referrals. It also prevents physicians from self-referring to certain facilities in which they have a financial interest. It’s got safe harbors for employed physicians of group practices, and for a variety of other cutouts. It’s hugely complex, and technically only applies to Medicare (& I think by extension Medicaid) patients. It doesn’t prohibit the doc from referring to the hospital that their partners also staff. You should read up on it — I think you’d find it an interesting read. (not sure what that says about you…) There may, I recall, be a requirement to disclose when ordering imaging that the patient can go to any imaging center they choose, if you are referring them to a center you own. Beyond that, though, I’m not aware of any obligation to disclose conflict of interest.
In my experience, most ER referrals are either directed by what I really think is best for the patient (i.e. I think the local community docs have crappy skills intubating kids and if your asthmatic goes south he will get better care at the Mecca) or just local referral patterns: ok, your PCP is Dr Jones and he is aligned with Multicare which just bought this place so I’ll refer you there; or Dr Jones hates specialty group X so I’ll refer you to specialty group Y; or it’s an even numbered day so this group is on call for ER referrals… you get the idea.
Speaking as a doc who has negotiated many contracts with our local payers, I personally have no clue what the docs (let alone the facilities) charge at outside facilities (and as an anti-trust matter I’m generally prohibited from knowing the other docs’ fee schedules). And I’m financially savvy. Most rank and file docs don’t know what they charge for a given service, let alone the facility fee.
Happy to explain in more detail if there are further questions. Hope the kiddo gets better.
benw
@efgoldman: I feel you.
chopper
@delk:
daaaaaaaaaaamn
Kineslaw
Hope your little guy is feeling better.
The Stark law is supposed to prevent physicians from self-referring in certain cases, but it has a lot of holes. The biggest one is that it does not require the doctors to acknowledge their financial interest in the provider they are referring you to, just that you have the option of going someplace else.
Mai.naem.mobile
I know under medicare regs if you’re in a facility you’re supposed to inform the patient that if you’re referring to an ancillary provider that the facility is owns the ancillary provider. The thing is it’s usually buried in the discharge instructions. I’ve seen it in the d/c.instructions at Banner here. TED radio had a repeat talk.about a physician who was pushing for disclosure by docs of all their possible conflicts of interest. She basically recieved what I would consider threats to hurt her and her family. She was hacked etc.etc.
Crusty Dem
@BubbaDave: @Liam Yore:
These two * 1000. The docs don’t have a clue or any interest in who is affiliated with who and what the billing is. They’re telling you where they’d go if it were their kid. Maybe they heard a malpractice horror story from the community hospital. Maybe they know docs from both hospitals and view the specialty as better. Maybe they golf with the specialty hospital docs. I wouldn’t assume the specialty hospital is better because the ER doc recommended it*, but I wouldn’t subscribe ill motives based on billing which the doc is very likely ignorant of.
* that said, my mother died in a highly ranked university hospital after a nurse decided to take off her oxygen monitor because “it wouldn’t stop going off”. She was there for chronic lung issues.
Crusty Dem
@efgoldman:
I almost understand it in certain busy ERs. She was on a regular floor getting IV antibiotics on a fairly quiet Saturday night (day 3 in the hospital?). Just a complete failure.
Richard Mayhew
@Liam Yore: this is awesome info and I will enjoy reading the act.
Little guy is on my lap watching cartoons.
KPed
@efgoldman: It’s a real entity called alarm fatigue. I’m an OB, and there are things going ping all of the time – IV blocked, fetal heart tones drop below (or go above) a preset limit, the epidural bad is almost out of medicine…you get the idea.
It is a problem, since many (?most?) alarms are false ones, yet we need to be aware when they are not.
Hillary Rettig
@Richard Mayhew: good to hear it!
WaterGirl
@Crusty Dem: That’s horrible. I’m so sorry. I know we declined to pursue legal action when even the nurses told us we should after my mom died, but damn, I hope there were consequences for the nurse who was responsible for your mom’s death.
dr. bloor
Sorry to hear about your son. Asthma is one scary bitch.
I’d be genuinely surprised if you got anything other than a blank stare from the referring physician if you outlined these issues to him/her. The doc’s job is to make sure your son is going to have any/every element of appropriate care on hand should a crisis re-emerge, full stop. Referring to someone/someplace else “in the system” with more than what your son is likely to need isn’t so much a financial scam as much as its the simplest, quickest way to send the patient somewhere you know his needs will be met.
I don’t think you can hold the referring physician responsible for “comparison shopping” any more than you can realistically expect it from the patients.
Shakezula
@Liam Yore: States also have laws that mimic or are even stricter than Stark and the Anti-kickback statute.
Right, that was added to Stark a few years ago. Doctors are also required to notify patients when they have interest in a physician-owned hospital.
Before diving into the federal register, however, I’d recommend user-friendly summaries of the Anti-Kickback statute and the Stark Self-Referral rule. (Many health law firms have them.)
And start with the Anti-Kickback statute, it’s much easier to understand than Stark.
P.S. Yay, a provider who knows about Stark and Anti-kickback law.
P.P.S. To the original question- No. I would not expect providers to know about other provider’s billing/payment systems. But new payment models may change that. Hope the son is feeling better.
SW
Richard. Many years ago when I was a grad student I worked as a pediatrics counselor at National Jewish Hospital in Denver Co. They have an in patient program for kids with severe asthma that is really quite amazing. In the meantime, don’t skip the hot water or tea before you escalate to the inhalers. Quiet time with breathing exercises and that old fashioned approach at the first sign of wheezing can prevent a lot of visits to the emergency room. Best of luck.
Frank Wilhoit
Richard,
Your question is not the right one. The right question is this:
How much medical credibility did that doctor lose with you for having given you a recommendation that manifested a financial conflict of interest on his part?
Speaking only for myself, I would have immediately begun searching for an alternative to dealing with him or with his practice. I would of course have been prepared to discover that there was no alternative. But if compelled to continue dealing with him, I would have aggressively second-guessed every one of his diagnoses and recommendations and his motivations for making them. In short (and in unworthy and infantile language), I would have stopped trusting him.
dr. bloor
@dr. bloor: Just to add that from the doctor-patient dynamic point of view, you understand you’re the exception here, right? The scenario where a parent gets pissed off because the physician referred their child to some generic community hospital when a specialty site was available plays out 100,000 times more frequently than your framing of the process.
Starfish
I hope he has a prolonged stretch of being able to breathe soon, and the steroid fights off the inflammation.
Comrade Luke
Putting this here, since it’s Richard’s purview.
Potential big changes, at least in my state:
http://www.seattletimes.com/seattle-news/health/group-health-members-meet-to-examine-proposed-buyout-by-kaiser/