In Pursuit of Preventive Medicine
December 2, 2011 1 Comment
By Matthew Kopetsky
During grad school, I benefitted from the mentorship of one of healthcare’s masters of change, David Gustafson. During his more than 40 years as a professor in the University of Wisconsin’s Industrial and Systems Engineering Department, he has directed the NIATx, CHESS, been the principal investigator of the TECC project, chaired the department, and found time to mentor, in addition to myself, two of my relatives. I remember, during one of Gustafson’s guest lectures in a change management course, his account of the inspiration for the Network for the Improvement of Addiction Treatment (NIATx). Instead of reading about addiction, he actually posed as an addict and actively pursued recovery, eventually checking himself in to rehab for several weeks. The broken processes and unsupportive rehabilitation environment that he observed shocked him enough that he has dedicated decades of his life to improving them.
A few months ago, I accidently had my own Gustafson-esque inspirational experience as a consumer of healthcare. It had been several years since my last physical and, as a healthcare consultant, I began to feel hypocritical not maintaining my own personal long-term health plan. My intentions were noble – pursuing preventive medicine – however, the experience left me wondering why, despite my good health, that I even bothered.
Finding a PCP
A family friend Physician suggested that I pursue a Primary Care Physician (PCP) in my area who is known for being “great with young, healthy males.” Unfortunately, due to my travel schedule, I’m only available for appointments on Fridays and he only saw patients Monday through Thursday. So, since the Physician practiced within the network of a large medical teaching facility, the receptionist suggested that I see a Resident. My appointment was made for the following Friday and I assumed that the all-important “referral” had just taken place.
Getting to the Appointment
Since I hadn’t received driving directions after making my appointment, I arrived (early) at the address listed on all of the pre-appointment paperwork that I had received in the mail and already filled out. After many blank stares from the business office personnel who had sent me snail mail, I finally obtained the Resident’s number and learned that he was at an office on the other side of town.
Two hours after my appointment was supposed to occur, I was in an exam room with a Resident (and my boss was wondering why I still wasn’t back from my appointment). The Resident asked me why I was there and, after I explained my desire to get a physical so that I could have peace-of-mind for another several years, he was shocked that I would get a physical in perfectly good health. In response to being asked what I would like him to do, I suggested several things which I thought to be normal male physical protocol.
Several months later, while enjoying my healthy peace-of-mind, I received my hospital bill for the charges which my insurance company deemed Patient Responsibility (~$200). Then, a couple weeks later, I received the entire Physician Bill because my insurance company had denied the entire Physician balance, deeming the visit out of network (~$400). So, after an inconvenient visit to a Physician for preventive reasons, I was left with a $600 bill and the quality of my health was exactly the same. Unfortunately, most consumers don’t understand their insurance plan’s detailed Explanation of Benefits (EOB) well enough to know when charges are denied in error (in defense of consumers, I have had to review EOBs professionally and they can be very confusing). Since I knew the referral for my care was legitimately from the office of my PCP, I pursued an appeal of the denied Physician charges. After several phone calls, I was informed that I could either fax or mail a formal appeal of the denial decision to my insurance company (no e-mail since the process needed to be as difficult as possible). After the fax number that I was provided didn’t work, I sent an old-fashioned letter and hoped that (in 4-6 weeks) my appeal would be honored (and my credit score wouldn’t be affected by my delinquent Physician balance). Fortunately, the insurance company approved my appeal and paid nearly the entire ~$400 Physician balance.
What would Gustafson do?
“…hopefully by the time my loved ones need complex critical care, I will have solved enough of the simple issues that their healthcare experience will be more positive.”
Unfortunately, the healthcare industry hasn’t evolved into the most user friendly experience. Even when consumers try to be proactive about their care, it is at the very least an inconvenience. However, in my non-urgent care experience, there are many simple things that could have been handled differently which would have left me with a more positive experience. The biggest positive outcome from my experience was a revitalizing reminder of what inspired me to enter the healthcare field – hopefully by the time my loved ones need complex critical care, I will have solved enough of the simple issues that their healthcare experience will be more positive.