Healthcare is available at many locations, such as in the medical home (primary care office), at a specialty clinic, in a hospital or a surgery center, freestanding urgent cares, pharmacy based urgent cares, emergency rooms, telehealth companies, school health clinics and more.
There are places that are best suited for one issue and others suited for other issues. Sometimes people choose a location based on what’s convenient at the moment, not necessarily when and where they will get the best care. This usually isn’t going to make much of a difference, but it can have implications of varying consequences.
The one about the restaurant
My family likes to go to Primary Restaurant for great food. We know the food is high quality and the chef takes special care to make everything just right with healthy ingredients. The staff gives great service, always making sure we have what we need. Because there’s always room for improvement, they encourage quality development and the restaurant staff works to make things right to the best of their ability if a problem is identified.
But one night we decided to go to Convenience Cooks. We were hungry and Convenience Cooks was on the way home.
Were we starving to death? No. We had food at home we could have eaten, but Convenience Cooks was, well… convenient. Their menu was limited compared to what we are used to, but we were able to order something that was decent.
While we were waiting, I decided to call Primary Restaurant to see if it was a good choice or if we should leave and go to their restaurant. They said since I made the choice and was already waiting, I should just stay at Convenience Cooks.
The food wasn’t the quality we were used to, but we ate it. I had second thoughts at the end of the meal, so I called the Primary Restaurant to see what they thought. The staff who is usually so helpful wasn’t of any use helping me decide if what we ate was good for us or not.
Since none of us felt satisfied and left still hungry, I feel like Primary Restaurant should deliver food to our home, but they refused. They said we should go to Primary Restaurant to eat if we want their food. Why? I already paid Convenience Cooks and had most of a meal there.
Weeks later I get a bill from Convenience Cooks and am surprised about the cost of convenience, so I call Primary Restaurant to see if it’s usual for Convenience Cooks to bill added fees. Again, they said they couldn’t do anything to help with the bill. For a Restaurant that is usually so helpful, I feel like they are dropping the ball because they won’t help with anything that was done at Convenience Cooks. It’s like they don’t have any responsibility for what I eat elsewhere.
The one about specialists
In another scenario, you really want a good BBQ. Primary Restaurant specializes in All-American food, but they don’t offer slow-cooked BBQ, so they refer customers to BBQ-R-Us.
BBQ-R-Us is busy and requires reservations. Since you are used to same day seating at Primary Restaurant, you ask if they can get you preferential seating at BBQ-R-Us. After several phone calls back and forth with staff at each location, you realize you can be put on a waiting list, but no one was able to change your initial reservation.
When that time finally comes, you enjoy the ribs, but leave with questions. Instead of asking the BBQ specialists, you call Primary Restaurant to ask about how the ribs were prepared. You’re disappointed to hear that they can’t give details about the BBQ recipes and tell you to call BBQ-R-Us.
Even later you call Primary Restaurant to complain about the bill you got from BBQ-R-Us. You were surprised that the creamy corn was extra and they charged a seating fee. Again, Primary Restaurant isn’t very helpful in discussing the bill from BBQ-R-Us. They refer you back to BBQ-R-Us.
now change the names
Most people can see just how crazy it is for a restaurant to “fix” the problems with quality, cost, or service at another restaurant, yet many (MANY) people want their primary care physician to do just that after trips to convenience urgent cares or regarding specialist referrals. The scenarios above are based on real phone calls about medical care. These phone calls are not only time-consuming and costly for medical offices, but they’re also frustrating for the people on both sides.
Convenience Cooks = Urgent Cares
I’m sure I’m not alone when I get frustrated at the number of calls asking me to give an opinion of treatment received elsewhere, or to fix a problem that wasn’t fixed at an urgent care. I’m glad that patient families feel so comfortable with my office that they call to ask for help, but if I am not a part of the evaluation, I can’t help.
It’s not that I’m holding a grudge or trying to be mean, but I really can’t help. If I didn’t see the patient or at least have access to the medical record of the visit and know the provider well enough to understand their practice style, I have no idea what was really seen and done.
If you call my office because your child is having a problem with a medicine someone else prescribed, we will tell you to call the place that prescribed the medicine. We cannot manage what someone else prescribed. Often we hear that “they’re not open yet” or “they don’t do phone calls, they want us to come back.” Sorry. We will want to see your child before we treat him for this issue. You can bring him in or you can follow-up with the original prescriber.
On a similar note, if a patient sees someone else in my office, I can look at the medical record documentation. I know the people I work with well enough to know what they typically say and do, and along with their written plan I can usually offer assistance if they’re not available. Sometimes even then I will want to see a patient because symptoms change.
If someone outside my office sees a patient, I really don’t know what the level of exam was, the experience of the provider, or the specific details of the visit. Urgent cares are getting better at sending a summary of the visit to the primary care provider, but we still don’t receive any information a significant percentage of the time. Other than routine general advice, I can’t really say much about the issue. I cannot change or refill another provider’s order. I cannot order labs or x-rays based on another provider’s assessment. I believe that this is not good care and I would prefer to see the patient if they need advice or a change in the treatment plan from me. And I certainly can’t do anything about the bill from another provider.
Many problems seen at urgent cares can wait. I know it’s easier to get your child in tonight so they can maybe go to daycare/school tomorrow, but many of these things are viral and just take time. Even if it’s strep throat and they start an antibiotic at 8pm, they can’t go to school in the morning. If you would have called my office before going to the urgent care (or looked on our website for advice), chances are the issue could have waited until office hours by using some at home treatments to make it through the night.
The cost savings of staying out of an emergency room or urgent care can be substantial with many insurance plans. And my office would be available to help answer any questions that arise from that visit. (Note: sometimes when the symptoms change we still need to see a child again, but we are more likely to be able to help over the phone if we were the ones who saw the child than if they were seen anywhere else.)
There are now some urgent cares that are actually cheaper in dollars because of insurance contracts. I think this is a very short-sighted plan on the part of insurance companies and in the end will cost more in dollars and health complications. They are trying to save money by contracting with these urgent cares (or are merging with them). I worry that fragmented care will in the end increase costs because they won’t have access to a patient’s medical chart. Increased numbers of tests and prescriptions are often seen at ER/UCs compared to primary care offices because they don’t have a means to follow-up like the medical home does so they cover all the bases rather than take the watchful waiting approach that PCPs are able to take. At urgent cares patients will not have the benefit of seeing the same provider each time, so they will never develop the important doctor-patient relationship that can help if and when anything chronic develops.
BBQ-R-Us = Subspecialist Referrals
As for specialist referrals, I know it’s hard for people to wait for appointments, but I really can’t get people in any quicker than a schedule allows. If it is a real emergent or urgent need, I can talk to the doctor to see options, such as admitting to the hospital so they can be consulted, or having someone go to the ER, where they might stop by to see the patient. Usually it isn’t really that urgent from a medical standpoint, and waiting for the appointment is just what happens in the specialist world. I’m not saying that’s a good thing, it’s simply reality. Please don’t beg me to call them to get you in sooner. I cannot invent time and I can’t alter their schedule. Despite what the scheduler tells you, if the primary care doctor calls the specialist, the specialist rarely can get the appointment changed. I’ve done this frustrating scenario many times– often when I really want the child seen sooner than scheduled. Unfortunately it usually doesn’t significantly alter the appointment time. It just wastes my time and the time of the specialist.
After your appointment I cannot tell you if the treatment plan they propose is the best for your child. Once I refer, it’s usually because it is out of my knowledge base and needs specialist care. I can learn along with patients, but I rely on the specialist to know the latest and greatest in their field and they can give better advice than I can. I also don’t like to “step on toes” if I refer. If they are driving the bus, they need to drive. Back seat drivers can cause problems on the road. Let them drive the bus. If you really want another opinion, you’ll have to ask another specialist.
Expect higher fees any time you use a hospital based facility, whether it’s for an office visit, a lab, or a procedure. They not only have charges for the physician’s time, but they have facility fees to cover the costs of running the hospital.
The primary care physician cannot change the charges incurred at any other clinic or hospital. We recommend researching costs prior to care, but we know that this is very difficult unless you know exactly what will be done at every visit. We cannot tell you what another physician will do… I can’t even predict what I will do at a visit if you call me ahead of time. If your child has a fever and cough, I might send you home with at home treatment instructions without any expensive tests if the exam supports that. I might order labs or a CXR, prescribe a medicine, or admit your child to the hospital for treatment if the findings support that.
It’s hard to anticipate costs, and that’s a problem with our healthcare system. I know that, but it’s not in my control to fix that. Believe me, I understand as a consumer how frustrating and expensive healthcare can be.
We try to help by keeping a list of all our most common charges in the parent book in each exam room, but that doesn’t help plan before the visit. It only tells the maximum that will be charged, not the actual amount that will be the patient responsibility after insurance adjustment and payment. I understand how frustrating medical costs can be, but I can only help with what is in my control. I cannot control how our billing and insurance system works. I can only play by the rules.