The Bait and Switch

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“So, now that I am on Medicare, the managed care company sent a PA to my house. They told me I needed to be on a generic cholesterol medication.” He frowned disapprovingly at me, like I had done something wrong.

Oh, really, now?

“Did you tell them that you have tried all of the generic cholesterol medications and they either did not adequately treat your cholesterol or they caused body aches or other side effects that prevented you from tolerating it?”

“You know, to be honest they didn’t even ask…” He absently scratched his scalp with an index finger. His face relaxed.

It’s Ok, I get it. I know what they are trying to do when they are sending people into new enrollees’ homes to “review” their health….

The company wants to spend less, so they tell patients that they need to change their meds to generics. Except that I only use generics whenever possible. I don’t use the expensive brand name meds unless we absolutely have to. 

And maybe I am being too sensitive or reading too much into it by feeling the insurance company is trying to undermine my rapport with the patient by having them question my clinical judgement but that is sure what it feels like. I worked hard for that rapport and unlike those company people, I really don’t have any ulterior motives at play here.

Too many cooks spoiled the broth…

This trend is popping up all over the place, even with private insurance. They pick the patients they are spending the most on and have a nurse call them once or twice a month. 

“We see from your biometric screening that you are morbidly obese. Why won’t you loose weight?”

As a patient if you have your doctor talk to you about your weight at an office visit and then a few days later some stranger, a case manager, calls out of the blue to talk about your weight, don’t you feel like your doctor ratted on you? 

I didn’t. I promise.

Weight isn’t like tobacco smoking. You cannot simply harass someone into getting skinny, but they sure as hell are going to try because that is the perceived root of all problems right now. 

Skinny people cost less.

The elderly are increasingly becoming targets. I can think of certain instances where patients needed a case manager, someone to help them use their benefits, navigate the system, make it to appointments, help with medications or checking vital signs. But those people never seem to get that kind of help.

A few months ago an elderly couple grinned widely at me during their tandem appointment. They were clearly excited. Each appointment for the past ten years they have brought me a detailed list of their daily blood pressures for the months since their last visit. This time, however, they had brought no such paper.

“Doc, a lady from the insurance company came out to the house and gave us a blood pressure monitor. She told us to check our blood pressure with it once a week. It is supposed to send that reading to you! Technology is just great nowadays.”

“Uh, those numbers aren’t going to me.”

“What?” They looked at each other and then at me, confused. “We thought…”

“They are probably going to the insurance company. Did they tell you what they were going to do with that information?”

“Well, no. No they didn’t. You didn’t tell them to send it over?”

“No, I’m sorry. I did not. I had no idea they were going to do that.”

What’s worse is that they were given the wrong blood pressure guidelines by the nurse practitioner that dropped off the monitor. You don’t tell an 80 year old to keep their blood pressure under 120/80. You just don’t. Guidelines indicate under 150/90 is the correct target for these patients as lowering further increases the risk of falls. And yet she told both of them that their blood pressure was too high and that they needed to discuss changing their medication with their doctor. 

But we are helping people, improving the quality of their care!

This sort of thing isn’t going away. It is only going to get bigger, more invasive. I will be placed in a more defensive position than I already am as insurance companies and managed care try to reduce costs further. 

Quite frankly, I don’t even know what to do about it at this point… Can it be a good thing? Sure, if we are able to work together somehow.

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106 thoughts on “The Bait and Switch

    • Not just seniors. Not just Medicare. Certain plans have this stipulation and who does or does not do it is a complicated thing that I do not even fully understand. I just know that over the past few months I am hearing about something like this once every week or two in my patient population.

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  1. Einstein once commented that “everything should be as simple as possible, and no simpler.” More people than not forget that last clause. To paraphrase for the business model. “everything should be as cheap as possible, and no cheaper.” More companies than not forget that last clause, just as they prioritize the stockholders over those they are supposedly helping. Market forces alone will not make this situation better.

    Liked by 1 person

  2. If nurses were sent to help patients (particularly the elderly or those who truly need additional help/support) in collaboration with their doctors, it would be wonderful. But this nonsense is at best confusing, and at worst, actually harmful to patients.
    It is interesting hearing a physician’s perspective.

    Liked by 1 person

  3. Oh, amen to this post! Things are getting pretty scary as far as I’m concerned and they’re only going to get worse.

    I do visit patients at home and try to make sure that they are getting what their doctors ordered. I can tell you right now, that 95% of the time they are not, they are getting whatever insurance company has decided they shall get. It takes a rare doctor that has the time to really throw a fit and push for what’s right, to have these things corrected. I have people with diabetes, you don’t need your meds, you just need this name brand testing equipment delivered right to your home, as if sticking this little machine on your finger somehow regulates your blood sugar. You don’t really need physical therapy, let me sell you this magnetic knee brace, medicare will pay for that..

    On and on it goes, I could write a bloody book about the convoluted mess that is our insurance regulated healthcare system, full of snakeoil and salesmen and con artists, all far more concerned about profit rather than patient care.

    Liked by 4 people

  4. I have private insurance. Right after my hospitalization for my colitis, I started getting calls from the insurance company “offering” to assign me a “health coach” to help me manage my daily health. I refused. I told the very nice young lady who got the job of calling me that if I had any concerns, I would take it up with my doctors, not with my insurance company. I don’t need my insurance company trying to override my doctors’ orders.

    Liked by 1 person

      • All I could think of was some sweet-tongued, falsely sympathetic nurse type telling me, “Don’t worry about that bleeding, hon. It will go away without any medication or intervention at all.”

        I wonder if those “health coaches” get a commission on the money that they save the company by telling patients to forego medications and treatments.

        Liked by 1 person

  5. I’m going to devise a generic stamp. “Insurance sucks.” Pretty well covers it.
    Except…if you don’t have it. And you need it.

    Pretty soon you will be reduced to, “Laughter is the best medicine, my dear patient. Here’s a prescription for an off-price copy of Calvin and Hobbes. It is the only thing your insurance will cover, because, well: best.”

    (And those people have jobs.)

    Liked by 2 people

  6. Always interesting to read how things are working behind the scenes. And that’s rather scary, them giving out advice that contradicts yours, putting patients at risk.

    My insurance co. has been calling the past few weeks. A “life coach” needs to talk to me. Apparently, between my own screen and the survey I had to do online for them, I have been deemed a “high risk.” I won’t answer, though, they cans figure out that I’m still alive and kicking when they get the bill from my dr.

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  7. I remember when managed care came into Home Health and they decided that people did not need a visit from the Home Health Nurse or maybe just one. Then Medicare followed suit. We actually kept people alive and prevented hospitalizations but it looked better on the books to cut out those “expensive” home health visits. Well if somebody dies you don’t have to pay for their care anymore do you.

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  8. Not only is this dangerous, I think it is probably illegal (it would be in Canada). These insurance companies are practicing medicine without a licence and they are accessing personal health information that should remain confidential with the doctor.
    Leslie

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  9. I so honor your being a voice to share with us from a different perspective of “the field”, and appreciate your candor. One of my family members who was a physician’s office manager said the huge flags went up when she observed warfare in the storage room.First one, then another pharmaceutical rep were pillaging in the drug sample closet – pulling the competitors’ samples. Hmmmm- where does it end?

    Liked by 1 person

  10. I really just don’t believe it. There is no way the Insurance people (If you have private Health Insurance) can interfere between a patient and a doctor. But, there are many ways in which we Australians slavishly follow America that I suppose it will happen eventually.

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      • Just because something seems wrong does not mean it is illegal, unfortunately. What would be the premise for illegal in these situations? (I ask because I am curious what your answer would be.)

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      • You have a VENDOR’s employees giving a patient medical advice without consulting the patient’s chart or physician. And these employees are LESS medically-qualified than the patient’s physician, and could, most likely, should this go to court, have multiple cases cited to show they too often gave some p#ss-poor advice.

        I think a lawyer would have a field day, in civil court, but I also cannot believe there aren’t Healthy2000-related regs being broken (or whatever Federal health statutes we’re under now).

        Liked by 1 person

      • Malpractice, yes. Illegal, no. Unfortunately no one will do anything about that until someone dies. And they are not vendor staff. They are employed by the insurance company.

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      • This is where I THINK I remember precedent: Because they are sending medical personnel out, they are implicitly representing themselves as a medical organization, and, by extension, their representatives qualified to give medical advice on a par with the patient’s medical doctor–who knows the patient’s history. Even more because they are catering most often to a senior population.

        The ONLY way I can see what they’re doing as facing court challenge is if they put all advice given in writing, with copy going to the real doctor, and if they got a signed release from the patient acknowledging that all advice given should be checked with her/his doc.

        Otherwise–I think they’re wide-open, legally. Victo, you’re friends with doctors, and many doctors are friends with lawyers–perhaps you can start a chain and find out?

        Liked by 2 people

      • The power of the popular post-er!
        πŸ™‚
        I am excited to learn. I will hope I am right and some lawyer’s cousin, just starting out, makes her/his career on this. But as soon as I began typing that, I realized you must be correct, or some lawyer would have already made a fortune.
        😦

        Liked by 2 people

  11. This reminds me of some creepy plot out of a Robin Cook novel. Soon the Insurance companies will be sending some type of Androids to the house to take people away when they are considered high-risk – Insurance companies have way too much power.
    I work a sub-specialty Out-Patient clinic and we battle every single day for the simplest of things, and the families get caught in the middle. A lot of our families are not English-speaking and so it makes it even more difficult and frustrating for them to get the medicines and treatments their children need. It’s really awful. We are always looking for ways to get around the road blocks the Insurance companies put up.

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  12. I have to say, it’s no wonder many Americans are so anti- “government” funded health. If any time there is more regulation, it is done poorly, incorrectly, or without patient consent or under false pretenses, it is sure to breed anger and resentment. That is so wrong and invasive!

    Liked by 1 person

  13. That is so sad that they are undermining your relationship with the patient. And the patients don’t even know that the company has an entirely different motive and they are not looking out for the health of the patient. They are looking out for their pocketbook.

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  14. We are looking at many things at our agency and one of them was the cost of supplies, “Silver” (wound care) products especially seemed to be flying out the door. I won’t go into the details, but of course the Admin thought theft and black market. NOPE! Turns out the nurses were taking it for their poor patients and stocking it because the insurance companies are deny paying for it. So you have this terrible wound that requires quite an involved intervention. The Doctor orders it and we go out to do the wound care only to find out the insurance company is not going to pay for it. So WE are supposed to tell the patients, not them, “sorry Granny, you have to cough up (private pay) for this treatment,” as she finishes her cat food dinner.
    I have a ton of tales like this. I hate insurance companies, not only for our patients and billing reasons but for my personal dealings. Our PPO has that nurse coach thing where they call you and lecture you on things. I got a call once and said, “do you have my health record?” “Well of course we do,” she said. That alone pissed me off. I said “and you have the place where I work and I told you what I do, correct?” She reads back the name and my title and pauses… I calmly said “and I need what kind of support, a nurse? I think that’s what you said.” I waited and she said nothing….. I hung up. Next they will be calling the MD’s so be prepared.

    Liked by 1 person

  15. The insurance companies have been dictating so much about our care for years now, I love it when a case manager, not a physician….from the insurance company requests a call from the doctor about a patient in the hospital who doesn’t meet their “criteria” for being there that long… because all people should take the exact same amount of time to recover from each particular issue. And the insurance companies hire nurse practitioners–in fact I did consider that very job…. to work in various capacities, often in the long term care and skilled nursing populations to help manage patient care. biggest issue??? not communicating well with the doctors. For some reason, so many people find collaboration too difficult, and it feels more like a tug of war over the patient. Unfortunately, only the patient loses.

    Liked by 1 person

  16. That’s insane! And it’s so sad that so many people are trusting and unsuspecting that there is an agenda by the insurance companies. 😦 I’m sure that puts you in an awkward position as well to have to deliver the bad news.

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  17. Wow, that’s a tough one Victo. That doesn’t happen here in Canada, at all.But, you know it is a shot at a system that think , if done correctly, could save a lot of money and time and maybe even lives – an advocate. I can tell you from personal experience that when going through a major illness, navigating the “system” is far more challenging than obeying doctor’s orders. If I had had an advocate with a broad knowledge of medicine (learned from experience and some training) I would still have my kidneys and would have saved the system millions of dollars. There was aside effect of radiation treatment that caused scarring in the ureters causing a back up and destruction of the kidneys. I had no clue what to look for so even though I saw a radonc every 3-6 months after treatment, I did not know what to report to him. There were clear signs but to me they were not related to the radiation.

    That being said, the advocate system has only been tried sporadically in various countries.- from a CPA’s perspective, it is a waste of money. Someone who sees the day to day life of a patient would be quick to catch any anomalies and could refer to a doctor. The key here being that the advocate communicate and act as the eyes and ears of the doctor. I had another medical anomaly occur due to radiation treatment (that stuff is wicked and can apparently cause side effects for as long as 25 years) and the doctor told me that it was my decision whether to operate or not to address it. I got upset at him and told him that I was fine to make the decision but he had all the information. He listed a slew of medical papers describing the issue and I looked them up and read them. I chose to live with the issue (internal radiation fistula) due to the high risk and probability of a recurrence. But an advocate could have acted as a go between and given me the relevant gist of the papers and maybe even cases where the same issue had been addressed. Reading medical papers without the training of a doctor is not something that very many patients would even try.

    My point is that I understand the concept the insurance companies are pursuing, but as you and your readers have so eloquently said – it has to be in conjunction and communication with the doctor. They are acting as a third party and basically competing with the doctor. That can only have a bad end.. As far as the legality that OB questioned – the American system of capitalism allows a great deal of leeway in dealing with privacy and other issues. Basically if you are purchasing a service, the vendor has way more “right” to advise, control, access than is usually permitted in other socio-economic structures. It is generally accepted and permitted that the relationship between a buyer and seller is sacrosanct and holds inherent freedom of information and action that supersedes other regulatory concerns. In studying business, we looked at case after case where certain business activities in the States would not be permitted in other countries. Always, it was protected by the belief that business relationships were primary and short of deliberate fraud, were acceptable. This has actually contributed to the US being the economic powerhouse that it is (whatever you focus on, that will become your strength) but it has brought with it some serious concerns on other fronts – such as your insurance company problems.

    Best of luck Victo.

    Liked by 2 people

    • There are patients who absolutely need an advocate and who could benefit greatly. Personally, I think anyone going through cancer needs one regardless because of the points you make. There is so much you don’t understand about it until you live it.

      Liked by 1 person

  18. We offer something call transition coaching. It is short term for now. The medical social worker (some are nurses) sees the patient in the hospital, goes over their diagnosis, and talks about how it will impact them and their lives and family. They then visit in the home shortly after discharge and then follow up with phone calls. They often will be in along with a visiting nurse and PT if needed. They go beyond clinical care, but do referral and social service support and advocate for the patient. It keeps them out of the hospital which is what the Mothership (URMC) wants. But it is a new program and limited for now.

    Liked by 2 people

  19. This provides an awakening to the insurance world and relationship with their clients, and the interference between Dr.’s and clients. Has any one measured the outcome health-wise that this interference has caused, particularly with the elderly?

    Liked by 2 people

  20. The NHS may be a bit bollocksed but there are a lot of times, reading your blog, when I thank god for it. It’s very clear that when profit and loss enter into the world of medical care it goes tits up. Then again, that’s why the NHS is a bit bollocksed… Sigh.

    Liked by 1 person

  21. Pingback: My Article Read (3-27-2015) (3-28-2015) | My Daily Musing

  22. These insurance companies can be a little all over the place with their formulary list and copays.. Sometimes I’ll see a copay for Crestor sky high… And then barely anything for their cialis… Because that is really necessary?! But they aren’t the person that has to get the money from people in person when they are picking up -_-

    Liked by 1 person

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