Tuesday, August 16, 2011

Additional thoughts on KevinMD's 6 Reasons Why Doctors Won't Call Patients Back post

In a recent post on KevinMD, 6 reasons why doctors won’t call patients back, Mary Pat Whaley gave a few reasons seemingly excusing these lapses in what should be a patient focused organization.  She also provided a few solutions. 
I have some first hand experience with this and in discussions with some of my colleagues, find that it is not an uncommon problem. I'd like to add a few more reasons and perhaps a few solutions:
1) Lack of professionalism among organization staffers.  There are many administrative people working within a practice today.  These people are hired for non-medical tasks and often have no formal training and limited medical office experience.  My guess is that few of them even go through the necessary HIPAA or medical office best practice training once, let alone attend yearly updates or refreshers.
2) Lack of adequate formal policies or procedures for dealing with the various types of calls that come in.  Even a simple checklist would make a significant difference here.  My guess is that there are probably organizations that provide this as part of a service.  Modules as part of the practice management systems would help here too.  One problem is that many offices are still working with billing rather than practice management systems.  This will change based on the new health care law.
3) Central offices for billing and administration - sometimes outside the practice itself.  We are seeing more and more group practices that are part of larger cooperatives for the purposes of holding the line on reimbursement, network management, managing administrative tasks (and associated costs).  While perhaps specially trained to deal with the nuances of the various rules of the insurers ie: how to code and how to bill, how to follow up to get paid, this is not part of the practice of medicine.  To these people, patients are just another number.  In other words, more managed cost, less managed care further exacerbating a problem that began with HMOs.
4) Appointment and/or referral desks are call back only.  This results in unnecessary wasted time to provide this function for the organization as well as the patient.  Why not task an entry-level staffer to take calls real-time while otherwise doing busy-work.
5) Overscheduling, understaffing, poor workflow.  To me, this one screams of a total disrespect for the patient.  How does a physician sleep at night, knowing he is keeping patients sitting in the waiting room 30 minutes and then a treatment room for another 20 minutes or more before walking in to see the patient?
Some recent examples from my own experience:
1) I had scheduled an appointment with a urologist about 10 days in advance.  An office admin called and left a message on my home machine to have appropriate labs with me when I came in.  I called them back and left a message to fax me a script for the labs so I could comply. This means they never checked if I had a script and then never called me back or faxed me the script so I could go to the lab before the appointment.  Why not have someone consult all patient files prior to or immediately after a visit is scheduled to prepare for an optimal visit.  I realize this can not be the case every time, same day sick appointments might be one example, but most of this time this could be a work flow game changer for all involved.  I have seen some practice management systems that attempt to facilitate this with some process the day before an appointment.  But it may need something a little more advanced for optimal effect on workflow. During the appointment, I was given a script for the labs and had to schedule another appointment to follow up on the results.  In this case it was not too bad since I had to come back to review the results of another test, but how many times does this happen to cause an additional cost (time and money) for the patient as well as the system for the follow up visit.
2) I needed a renewal for a medicine I have been on for years.  My current insurance requires prior approval in order to get this medicine. This means that the doctor has to call the insurer, a time consuming process.  Because the med was an as needed med, I had not had to fill it since changing insurance company’s last year.  Knowing the process, it was easier for the physician’s group to put off the pain involved by giving me a 6 months supply in samples.  “The next time I come into the office” for a billable event, they could take care of it.  Unfortunately this is becoming more common as plans try to push patients into generic (or rebate subsidized) alternatives.  The problem with this is that even if instead of prior approval, there was a step therapy requirement, it is a breakdown in the system.  More and more often, as patients have to move from plan to plan because of uncontrolled rate increases and higher deductibles, the history or experience of the patient does not come with them.  If a patient has been through step therapy or the other meds already under a previous insurer, why should they have to do it again if the medicine they are on works for them? Isn’t there a cost to this?  Unless there are new therapy alternatives, why force the patient through the process again? Why should a physician’s office have to spend the time on this without reimbursement?
Within her list of solutions Ms. Whaley suggests “The only answer to understaffing is technology.” includes a few ideas that make sense, but technology is not the real solution.  Technology is a tool or suite of tools; which must be used as part of a process and don’t necessarily define the process itself.  This said, ePrescribing would be a great step in the right direction.  This would include writing a new script, servicing renewal requests and even addressing changes for formulary issues that could otherwise be addressed prior to the script appearing at the pharmacy.  All of which takes time, in fact I seem to remember some statistic that physicians and pharmacies waste 30% of the day on the phone with each other to manage all of this.   Today, while ePrescribing can help for some scripts, it cannot be used for controlled substances - and there are still kinks in the evolution of this technology resulting in errors at the pharmacy. These issues will work themselves out over time but will have a real, though diminishing, time cost until they do. 

She also points out that “some patients will game the system to get their needs met ahead of others.” and suggests, “ask them to adhere to the practice guidelines.”  As per my point above, a physician’s staff needs to follow a set of practice guidelines, policies and procedures to provide an appropriate level of care and experience for their patients.

In summary, I think that some of this is based on a general malaise towards patients.  While this may not be intended by or on the part of the practices themselves, it comes across that way by the actions of their staff.  In the case of the insurer’s it is absolutely about money and shows little respect for the patients or the physician practices; it is all about numbers. This needs to change.  In the mean time how about patient needs being placed a little higher up the ladder?
 Thanks Greg B for the additional input.

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