Assigning patients to doctors. Who still does this?
We don’t assign hungry people to restaurants, hairy people to barbers, or passengers to airlines. Even State Farm allows me to choose between Maaco or my local chop shop every time I crash my car. We do assign kids to teachers, but still, I don’t need too many analogies to tell me that assigning patients to doctors is a bad idea!
The average U.S. worker stays at a job 4.4 years, and moves homes like 12 times in their life, each of which may cause a change in health insurance, doctor, or both. Even folks with one house and one spouse may have to change doctors when their employer finds a cheaper health insurance plan. On the other side, I would guess an average doc may change where they practice once every 5 to 10 years. Forget Marcus Welby, med schools need to teach how to practice in our age of discontinuity of care, using faxes, interoperable EMRs, and unsuspecting pharmacists to be a past medical history detective.
I can’t find any data on the average time a patient sees only one provider, but I bet it is not much longer than a relationship on Tinder. Really! I am basing this on my experience as a family practice doctor open three years, with 4,500 patient files, with an office seeing up to 150 visits a week. I have no similar experience with Tinder: I’ve just heard.
Yes, some patients are fiercely loyal to me, and me to them. But the majority will ghost if my waiting room is full, if I don’t give their baby whatever Dr. Oz said, or if my nose is too big today. I know even my loyal patients see other PCPs, just as a collar cam will reveal your cat having dinner at two houses every night. With today’s primary care shortage, many patients are lucky to find a provider with a pulse, nevermind doctor rankings, or caring if the provider is a PA, nor went to med school on the moon.
In other words, there are enough variables that affect what provider a patient sees, that we don’t need to be creating patient/provider arranged marriages.
So who would actually assign a patient to a doctor?
Kaiser does. People with Kaiser can not go to another doctor system, even if the patient knows they have cancer, and the Kaiser oncologist can’t see them for weeks (this is an actual example). Who else does this? In Denver it is called Denver Health Medicaid, which will fight you like a honey badger insisting the patient is theirs, nevermind that their line for care is longer than a theater on opening weekend for Iron Man 3. Imagine if McDonalds told you that, since you chose a Big Mac, you can never go to Taco Bell (even if they paid for the Big Mac).
These are two examples of managed care — the outdated notion of assigning patients to doctors — which has repeatedly been shown to not work for patients or save money. (Actually I haven’t studied Kaiser outcomes, but I know it doesn’t work with Denver Health Medicaid.)
I work in underserved medicine, as a for-profit private practice, seeing more than 90 percent Medicaid or uninsured. This payer mix is usually only served by health care nonprofits — both FQHCs and smaller entities — many of which I have found to be vicious when it comes to claiming patients. One to my south filed a medical board complaint against me, stating I was coercing patients to join my practice, and one to my north filed a complaint stating I was coercing patients to stay with my practice when they wanted to leave. There’s enough patients to go around, so why such fighting? Probably because they all compete for the same funding sources, so they would rather be seen with a line out the door than actually rub elbows with the competition (me). That’s OK; my business is booming because I have a pulse.
There are also systems that don’t bind a patient to a provider, but just suggest a provider. This includes many private insurance plans — e.g., Humana might assign a provider name on your card, but you can really go to any doctor who takes Humana. This also includes some accountable care organizations, where patients are assigned to one office, but can still go to any.
The irony in low-income health care is that people change jobs and homes even more frequently than high-income folks, and (if I had to guess) the doctors probably burn out of working at low-income clinics even quicker, all making it even crazier to think you can or should require a patient to stick with a provider for any length of time.
A head of a local free clinic told me his budget limits him to having 1,000 patients, as defined as 1,000 people in their EMR. I responded that I have 4,500 in my EMR, but I would never claim any of them to be “mine.” (Actually I didn’t say that, I just thought it. I also thought that I probably see a lot of his thousand and vice versa.)
I recognize that the insurance company sits in on every patient visit, but in my opinion, it should always be the patient’s liberty to choose who they want providing their medical care. Let the patient go wherever they want, every time. The only reason I can think of limiting patients to one system is to keep records in one place, but this notion fails in the face of health information exchanges. Now that I can instantly look up records at neighboring facilities, it becomes obvious that the most efficient solution is to let patients find their care, and let the doctors find the records.
It is OK to suggest me as a PCP, but please don’t bind patients to me for any length of time.
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