In-Network Doctors – Quantity over Quality

Last Friday, I went for an annual Ophthalmology “check-up.”  Since my Eyes are not my primary medical concern and I’m broke from all my other medical problems, I decided to “work my health insurance plan” to find a doctor and, in the process, take my own advice.  Mind you, while Crohn’s Disease and my Gut are to me what Kryptonite is to Superman (if you have never heard of “Crohn’s Disease Man” you just aren’t reading enough comic books), my Eyes are nevertheless of vital importance to me.  Moreover, the auto-immune aspects of Crohn’s Disease have been known to affect the Eye so it wasn’t like I was going to see a Podiatrist or a Psychic and could thus roll the dice.  In that regard, I apologize to all the Psychics out there for comparing you to Podiatrists.

Tolerating “Quantity over Quality” from In-Network Doctors

More seriously, I have learned to merely “tolerate” my Insurance IN-Network Doctors based on my present experience with an Endocrinologist who has more satellite offices than he does office staff such that it takes 3 weeks to get a Prior Authorization for an MRI of my Pituitary Gland.  I am STUNNED he calls himself a Doctor and not a Medical Businessman.  I haven’t terminated our relationship yet because I’ve had a hard time finding another endocrinologist in my insurance plan who can see me within six (6) weeks and, anyway, at this point in our relationship he is merely accumulating test results and my Bookie could basically do that.  However, I will change endocrinologists when interpreting said test results becomes of paramount concern and a long-term treatment strategy must be devised.

Since I am seemingly caught in this weekly vortex of needing to be treated by one medical specialty doctor after another, I don’t have the energy to take the appropriate consumer “stand” with each disappointing health care transaction I encounter.  However, despite my medically dominated day-to-day life and the numerous disabling medical issues I must contend with, there was something so outrageous about my recent encounter with this Eye Doctor that I had to “fight back” if only to show this doctor that the BS he is pulling with other patients can’t be pulled with me (and shouldn’t be pulled with the other patients).

Do you “take,” or “participate in,” my Health Insurance Plan?

You see, I had to find an eye doctor who would not only evaluate my vision but also assess the various eye ailments I’ve experienced because of my chronic illness.  In that regard, a trusted family member of mine recommended this particular eye doctor because he was very kind to her and had solved her then-pressing medical problem so I checked to see if he was in my health insurance plan.  I was pleasantly surprised to see that he was IN FACT, an “In-Network” Physician Provider.  I point out this distinction because patients get fooled all the time when they call a doctor and ask them if they, for example, “take Green Cross of Boston Health Insurance” and the $12 an hour receptionist says, “Sure, the doctor ‘participates’ in practically all health insurance plans” or “the doctor ‘accepts’ all health insurance plans.”

You may not realize it at the time but “magic words” are exchanged between patient and medical receptionist during such a conversation and medical practices have been profiting off of the resulting misunderstanding with the same ease of off-shore oil drilling companies obtaining licenses to drill for oil under President Bush’s administration.  The medical receptionist technically said nothing wrong because saying the doctor “participates” or “accepts” all health insurance plans when asked if the medical practice “takes” a certain health insurance plan is like pulling into a gas station asking if they “take” the local town Entertainment Discount Card and expecting a great bargain if they do.  The gas station guy would say they do “accept” the Entertainment Discount Card but the rub is the extent to which he “participates” in, or “accepts,” the local Entertainment Discount Card plan.

The Financial Ramifications of Healthcare “semantics”

For instance, the gas station guy might smile and take the Entertainment Discount Card Coupon but after you fill up your gas tank for $49.00 he will come back to the driver-side window and tell you the total is $44.00.  “But I thought you ‘accepted’ the gas coupon from the Entertainment Discount Card?” you ask.  Still smiling as if he’s a regular Saturday night dinner guest at your house, he says, “I do, and I deducted $5.00 off your total, so all you owe me for filling up your car with gas is $44.00.”  That’s exactly what happens in healthcare when the words “participate” and “accept” are misunderstood.  Moreover, medical practices exert zero effort to correct patients from relying upon these magic words.  But we patients have no-one but ourselves to blame because the only phrase of any financial significance is “In-Network Provider” because then the most you can pay for an Office Visit is your “Insurance Co-Pay.”  With my current insurance policy, that is $30.00 for an “Office Visit” and $50.00 to see a “Specialty Doctor;” however, I have yet to see an Office Visit which they classify as anything but an office visit with a “Specialty Doctor.”

Having been burned many times before by the aforementioned health insurance “take/participate/accept” semantic BS, I was legitimately impressed that my Health Insurance Plan had this particular Ophthalmologist in its Provider Network of Doctors given the rave reviews he had received from someone whose opinion I respected.   Since my Co-Pay is $50.00 to see In-Network Specialty Doctors, I was going to get a full Eye Exam and Overall Consultation for no more than $50.00.  Looking back on it, I should have realized that when something sounds too good to be true, it invariably always is.  There are a few exceptions to this age-old axiom but you usually wind up marrying them and I have yet to be so lucky to meet the woman of my dreams. In any event, when I walked into this new Ophthalmologist’s office last Friday what I encountered SO DISTURBED ME that after the Office Visit I decided to ask for my money back.

How to be a Medical Patient Consumer

Rather than bore you with additional details as to why I felt so ripped off as both a Patient and a Consumer by this Ophthalmologist, I have pasted below the EXACT Fax I sent to him on the following Monday, which he responded to within one (1) hour by reversing the $50.00 Co-Pay charge to my American Express Card.  In short, I felt like a patron at a trendy restaurant with a Server who starts walking away from me while I’m still ordering as if he knows how to complete my sentences and what I want for dinner that evening.  The Server seems more interested in maximizing his tips by “turning the table over” rather than in ensuring that I have a pleasurable experience.  In the restaurant setting, I can tolerate such behavior because I don’t have to jump through too many hoops to find the joint and after all, it’s common to have a “one-off” experience.

If I wind up having a bad consumer service experience, I’m also always aware of the “buyer-beware” credo and I can easily “complain” by never going there again.  I can also tell all my friends about how rudely I was treated and I can even write a scathing Yelp Review or share my bad experience on some other social media platform.  These common sense remedies notwithstanding, I think it is just as important to take the time to compliment a new restaurant or business via these same consumer tools when the experience is positive.  We all seem to have more time to complain and protest to get our money back than we do to compliment or praise a business or service when it provides exactly what it advertises.  That’s just human nature and when we spend our hard-earned money and in return get a bad experience we tend to be more “motivated” to do something about it even if that is to simply ease our minds.  But I do try to keep my complaints and compliments in balance and I think my Yelp profile can attest to that.

But these consumer remedies are not as effective when it comes to our Health because there’s simply too much subjectivity involved with the healthcare transaction and the “time spent” vs. “proper treatment received” quotient doesn’t leave much room for a grave error or a disconnect.  Accordingly, while an arrogant abrupt physician to some can simultaneously be touted as a highly skilled and confident physician to others, the time invested in developing a new doctor-patient relationship gone wrong can feel like the most squandered of wasted time.

“Quantity over Quality” In-Network Doctors with some Exceptions

Ironically, in the middle of writing this Post I went to see an In-Network Surgeon for a Consultation as I need rather serious surgery to repair Crohn’s Disease-related damage in my Intestine.  It may have been the most thorough examination I’ve ever experienced as this doctor focused on me and my case until he and I were both satisfied that we had all of our questions answered.  By agreeing to operate on me, he was telling me that my problem was now his problem and I left his office SO relieved.  Perhaps it was the combination of the precise nature of his surgical specialty and the seriousness of my surgery which warranted such individualized treatment, but I have found the recent increase in Insurance In-Network Doctors clearly creating a “quantity over quality” atmosphere.  I can only imagine this trendy restaurant-like atmosphere to be a byproduct of the unreasonable provider reimbursement amounts and the allotment of shorter and shorter patient time constraints placed upon them by both our overall healthcare system and by the rules of being an In-Network Provider; the Network of which many Provider Doctors are forced to join simply for cash-flow purposes.

“Turning over patients” seems to be the name of the game in these types of practices.  It is quantity over quality; “LA” instead of New York City; Kathy Griffin over Louis C. K.  The question then becomes:  What to do about it?  I decided to articulate my grips in a respectful letter to the aforementioned Ophthalmologist asking for my money back and in the process I hoped he “gets it” so that the quality of the medical services he renders to other patients in the future gets better.  Below is that redacted copy of the fax I sent him [underlined and bold emphasis left in].

The Redacted Ophthalmologist Letter seeking Refund

As an experienced Patient, and a complicated one at that, I was deeply disappointed in the Ophthalmology medical services you provided to me on Friday, ————, and as I result I am reversing my $50.00 ——————– Insurance Co-Pay Charge with American Express (if charged; if not yet charged I am respectfully requesting that you do not do so) and I respectfully request that you mail to me my Medical Records you and your staff generated on ————-.  My address is —————————————————————.  Thank you for your anticipated cooperation.

For the sake of explaining my actions and for the purposes of hopefully preventing this from happening with other patients, set forth below are my  specific Complaints.  In summary, I just need my Doctors to be reasonably thorough and reasonably comprehensive given how pervasive my Crohn’s Disease has been and you clearly were not.  But, it is nothing personal.  Candidly, I think it is a byproduct of the ridiculous and unreasonable time constraints you are placed under by Health Insurance companies which in effect unfairly place your emphasis on “turning over patients” like waiters in a trendy restaurant instead of treating each patient with the time and focus warranted by each individual patient and case.  Nevertheless, I need more attention focused on the health of my eyes given that my Crohn’s Disease has already had a significant effect on my eyes.  In that regard, I must now see another Ophthalmologist for the same reasons I went to see you and therefore I would appreciate you not charging me for the ————————— Office Visit/Exam or not contesting my reversal of said charge when/if it appears on my American Express Card.  Thank you for your anticipated cooperation.

The Specific Patient-Consumer Complaints

  • I completed your New Patient forms in reasonable detail explaining the Cataract Surgery, Eye Sores, Extreme Crohn’s Medication Side Effects and Dry Eye I have experienced as a result of my Crohn’s Disease yet you merely confirmed the Left Eye Cataract Surgery and told me I have a Cataract in my Right Eye but that I shouldn’t worry about it.  That gave me no gauge whatsoever as to the status of that right eye Cataract considering that my Los Angeles, CA Cornea Specialist told me 3 years ago that I must watch that right eye CAREFULLY.  You did not even inquire about the eye sores or the Dry Eye and both are often symptoms of Crohn’s Disease and in my case they were so EXTREME to the point where I had CUTS in my eye that were so painful I almost had to be hospitalized.  As for the Dry Eye, I had some type of ducts inserted into each eye yet you did not inquire about Dry Eye AT ALL.
  • I spent more time with your cordial Vision Technician than I did with you and that concerned me given the complexities explained above and given my current exacerbating problems regarding Reading up-close.  I was worried that my chronic illness might be somehow affecting my vision (as my Crohn’s is apparently active and wreaking havoc inside my Intestines as I am awaiting a surgical date to have FIVE (5) Strictureplasties performed on me) yet I was “run through the mill” that you have established at your practice and while that may be perfectly fine for normal patients it doesn’t work for me.  I also asked this Vision Technician several questions which she had no answer for and I also had to remind her several times to check the prescription on my Sun Glasses as I was not sure when I had them made.  She was very nice and professional but she went through my exam like she was completing a checklist fixing a car’s Transmission rather than treating ME as a Patient.  I don’t blame her at all; I have no one other than you to blame because she should not be placed in a position to answer questions which necessitated answers from an Ophthalmologist.
  • When you gave me the eye exam and I complained that my right eye was VERY blurry from the dilation eye drops yet my left eye seemed fine, you said I shouldn’t worry that the vision you were demonstrating for me in that right eye wasn’t the best possible vision I could achieve with a prescription.  To that end, I still don’t understand how you were able to almost perfect the vision in my left eye with the manipulation of the different lenses in that machine but never came anywhere close to providing me with decent vision in my right eye.  Considering I have a small or “beginner” Cataract in that right eye, have experienced all of the above related to my Crohn’s Disease and what I set forth in the New Patient Forms, your answer to my repeated question about this was unsatisfactory.
  • I also told you after you were done examining me that I was having serious problems reading the newspaper and you told me that you were surprised by that statement based, I imagine, on the eye examination you had conducted.  Then, in response to my statement and in an attempt to help me, you had me go back to the prescription “machine” and you held up a sign close to the machine for me to read to test my reading vision.  However, your hand was not steady and the sign moved and that just added another variable to figuring out what my correct reading prescription is because I couldn’t focus on the answers to your questions regarding what was on the sign but you did not seem bothered by it.  You then put the sign down and changed my reading glasses prescription.  I asked how you knew what prescription to write and you simply answered: “I made your reading glasses much stronger.”  ????  With all of the complexities that must go into figuring out the correct eye prescription, what does “much stronger” mean and how did you arrive at that exact prescription?  Moreover, had I not insisted that you please make sure my reading vision was optimized; you would not have changed a thing.
  • I asked you about the right eye Cataract and again you gave me a “wishy-washy” answer by telling me “not to worry about it.”  Given the almost 20 major surgeries and 200+ hospitalizations I have experienced due to my Crohn’s Disease, I must worry about it because what can go wrong with respect to my health, always seems to go wrong.  This is all not even mentioning that I developed, and had surgery for, a Cataract in my Left Eye in July, 2007, when I was 44 years old and was told it was directly due to my Crohn’s Disease because I was too young to be developing a Cataract.  I was also told at the time that I had what appeared to be a Cataract in the right eye but that it was too small to operate on – at that time.
  • Then you walked out of the Exam room leaving me on the chair and I thought you were either coming back in or having another vision technician come in as I still had questions regarding the prescription to my Sun Glasses.  Then, after waiting a few awkward minutes in the exam room chair, I walked out of the exam room and asked someone to check my sunglasses.  The Vision Technician who had conducted a variety of tests on me was kind enough to take them from me and she then checked them.
  • I also recall always having drops placed in my eye to reverse the dilation drops because my eyes are SO SENSITIVE to Dry Eye and whatnot but that was not done and I forgot to ask.  As a result, I had trouble seeing clearly for at least FOUR (4) hours after I left your office.

Dr. ——–, I could go on and on but it is not my intention to be unreasonable or vindictive.  The whole experience simply reeked of an office trained to “turn over” patients rather than to TREAT THEM and I cannot entrust my health and well-being to such a Doctor.  That said, I am acutely aware of the harsh realities of our current healthcare system and I do sincerely understand the ridiculous reimbursement and time constraints you are up against but nevertheless I do hope you take this letter in the spirit in which it was written.  That is, to explain my actions and to provide you with some feedback so that you can make some changes to provide a better quality of care to your future patients since you certainly seem like a smart doctor with the best of intentions.  Additionally, I do not think it is fair that I should have to pay for my eye exam with you since I must now go to another eye doctor for the same thorough and comprehensive eye examination I was seeking.

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One response to “In-Network Doctors – Quantity over Quality

  1. I applaud you for taking a stand against inadequate care. More patients need to do this and maybe the medical professionals will “get the message.”

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