My wife’s youngest brother has been struggling with a chronic disease, and recently required a surgical procedure to correct another problem that in itself was potentially life threatening.  To a certain extent, the longer term condition increased the risks of the required surgical procedure, and, therefore, good communication between his primary care provider, his gastroenterologist, and his surgeon was essential.  The breakdown of that communication was only one of the hurdles he has encountered on his path to recovery.

My brother-in-law is a hard-working family man, and belongs to a HMO through his employer.  The provisions of the plan require him to obtain a referral for any care or procedure not directly provided by the primary care physician (pcp).  The pcp is the “gatekeeper.” His office staff is very important, and powerful as the accurate and prompt filing of requests for referrals from the HMO is their responsibility.

Rather than rant about ineffecincy or blame specific persons ( which was my first impulse,)  I will describe how I think the system is supposed to work, and offer some helpful hints for those having problems with the system.

First, my background.  I am a retired general surgeon, “grew up” in medicine, at the start of HMOs, and saw them evolve to the present state.  After leaving the provider side of the equation, I worked as a volunteer medical insurance counselor, primarily for medically indigent individuals, and for those on Medicare, and also as a patient, myself.   I struggled with insurance companies, Medicare, and Medicaid systems in three states, and became familiar, and often, frustrated with them.

A Health Maintenance Organization was envisioned as an insurance plan that would save money for the consumer of medical care in several ways: by reducing inappropriate specialist consultations and excessive laboratory testing, providing more preventative care, reduce Emergency Room visits, encouraging follow-up, etc.  Some plans are large group practices with centralized record keeping, “in house” specialty consultants, even their own exclusive hospitals, ERs, laboratory and x-Ray facilities, surgicenters, etc.  Within this type of system, the PCP is usually quite familiar with the available consultants, and referrals can be made more efficiently than in some other plans.

Another HMO has a “looser” arrangement.  This type is offered by an insurance company along with various other plans such as a PPO, or other fee-for-service plan (Medicare, for example.).  A primary care provider in this plan may also be caring for Medicare patients or may be on the panel, list of allowable providers, of any number of PPOs.  But for the HMO patient, he is the gatekeeper, provides an initial evaluation of any and all complaints, provides the total care, ordering labs and x-rays, prescribing medication or PT, or other modalities allowed in the plan.   If the PCP sees a need for specialist consultation, he requests a “”referral” which must be approved by the HMO reviewer.  The specialist will also be on the HMO panel usually with a predetermined fee schedule.  Most HMOs will also consider a referral for consultation with a non-panel specialists, but again a reviewer or even a committee must give prior approval.  Also, higher co-payments by the patient may be charged.

Unless he or she has been through the procedure previously, or even inspite of being through the procedure before, the task of obtaining approval,for a specialist referral can be daunting.  Here is where the PCP and his staff can really make a difference.  Most patients that are faced with a new serious diagnosis, one that might require surgical or long term treatment, are frightened, in pain, and, to a lesser, or greater extant, ignorant of the prognosis.  They hear only part of what they have been told, and understand even less.  The “bad news” is a serious distraction from whatever instruction or advice follows it.

So, patience with the patient/family is needed.  Handing them a pile of paperwork to fill out needs to be followed with helpful hints, or even some “spoon feeding.” Patiently repeating instructions is often necessary.  There is no room for a “just routine” attitude.  The PCP must be clear with his staff and the patient in explaining the steps involved.  His/her input on the referral request should be accurate, detailed, and prompt, providing the details the reviewer needs, without having to call/email/fax questions and answers back and forth, unnecessary delays.

My brother-in-law is fortunate in having a savvy sister, a registered nurse, who was politely persistent in ensuring that the proper steps were taken.  The provisions of an insurance plan are often complicated, the plan should be “second nature” to the provider, staff, and patient for the system to work smoothly.  The policy holder/family should study the policy when first signing up, and pay attention to the frequent, seemingly insignificant notices of amendments.  When we are well, looking at a lengthy and confusing document seems a waste of time, but it will prove to be time well spent when urgent care  is needed.

(to be continued )