Sunday, February 17, 2008

Coordination and fragmentation - Falling Through the Cracks

Relatives, friends, and neighbors sometimes ask me how to navigate the system's thickets. They ask where to go, what to do, who to go to, what it will cost, and how much insurance will cover.

As a pathologist, too often I’m lost for answers. I tell them to ask their doctor. But some can’t find a doctor. Most have no doctor to supervise their overall care.

Here’s a typical story of woe. A fifty year old woman with arthritis and kidney disease develops atrial fibrillation. She now has six doctors –a general cardiologist, an invasive cardiologist, a rheumatologist, a nephrologist, a neurologist, and whatever hospital “clinic” doctor happens to be on duty.

She went to the clinic recently for relief from the flu and a migraine. A workup ensued. A $3400 bill followed. She had to pay more than half the bill. The clinic was out-of-network for her health plan.

“All I really wanted,” she wailed, “was Tylenol with codeine for my headache.” As she bounces back and forth between doctors, she observes many have no record what other doctors had done or advised.

Frustrated, she called me. Did I know a physician who could coordinate her care? I’m relatively new to the area. I didn’t know of anyone. I called around.

• I called a retired internist with whom I interned. He said he didn’t know of any coordinating doctor. He added he and his wife couldn’t even find a primary care physician for themselves.

• I called a young highly placed young health care executive. He said it took him six months to find someone to oversee care for himself and his family.

• I called a surgeon, a former head of surgery at a hospital. He didn’t know of such a personal doctor.

• Finally I called the former director of general medicine program at a teaching center. He knew of a wonderful woman general internist in a town 25 miles from where the patient lived. I used his name to refer the patient to her.

How do we heal and seal these cracks in health care?

All of us know the usual recommended solutions - large multispecialty clinics, electronic health records in doctor offices, portable personal health records, cost transparency by doctors and hospitals and health plans, educating more primary care doctors and paying them more.

These sensible suggestions will take time.

Meanwhile, I’ll have to call around and see how I can help fill the cracks for inquiring friends, relatives, and patients.

Can anyone give me any insights on how to handle this problem?

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