Baby babble (aka my first real counter with big bad insurance)

Yesterday I went in for a follow-up optometry appointment. Usually these are the most basic of basic medical encounters - you pop onto the doctor's exam chair, he ask you read a few lines of letters and numbers, tweaks with some lens combinations, and pops out a prescription for your glasses or contacts. Easy as that. I've had myopia (i.e. nearsightedness) for as long as I can remember, so these appointments have become entirely routine. As a recent grad with my first full time job, I thought that there couldn't be an easier way to try out my brand spanking new health coverage than this. I picked out a doctor out from the website that was linked to my company's internal portal, found myself pleasantly surprised that I was able to view and even compare information such as the MDs' credentials, comparative ratings, and patient population types. This, I made note, is what empowering the patient looks like.

The first time, I go in to see Dr. Soss on a Saturday morning. Upon entering, I'm greeted by his receptionist, Eileen, who seems more like an amiable librarian in the children's section than someone who deals with billing and insurance papers. Dr. Soss has a commanding, larger than life air about him, which is backed up and explained by the various plagues on his walls dictating his various memerships and leadership positions in local and national optometrist organizations. Personally, I prefer my doctors old fashioned - stethescope around the neck, kind eyes and a ready smile, and more of a listener than a talker. But I felt reassured by his commitment to his profession. The appointment goes as I expect; Dr. Soss even goes on to recommend an eye exam in addition to the normal lens exam, which I agree to. Out of professional concern, Dr. Soss suggests that I provide him information about my previous contact lens prescription so he has as much information as possible before he finalizes my prescription in a follow-up appointment. Again, as both a patient and someone who has thought a heck of a lot about the doctorly ethos, I was impressed by his diligence. After we finish, the librarian receptionist finds my insurance information in her computer, charges me the co-pay (we have a slight tie-up with my flexible spending account, but she provides me the papers to get reimbursed), and I leave with the understanding that I'll need to come back for another appointment.

Yesterday, another bright Saturday morning, I walk into the same office and am greeted by the same receptionist. But something was different; she tells me in a concerned tone that I'm no longer in her system. At first, I suspected that there must have been some mixup; what with it being the beginning of a coverage year of all, sometimes names might get lost in the system. I ask her to check again, but all she pulls up was someone with the same last name and first initial. It turned out that she had mistakenly billed this person for my last appointment, and that I was never in this system to begin with. She calls the insurance company with the vision plan, but then has to hand the phone to me as the agent tells me, after rattling off a professionally rehearsed greeting, that not only I, but my employer, are nowhere to be found in the database. I'm confused; I had clearly gotten Dr. Soss's information from my company's website, how could they not be an in-network provider? At this point, Dr. Soss emerges with his previous patient and gets an understanding of the situation. Apparently he is only a medical, but not a general optometry, provider within my plan's network (which, of course, my company's spiffy website failed to inform me of). Being of no help, he further tells me that since my appointment was already on the books, I'd either have to complete it or accept the $50 no-show penalty charge. Meanwhile, I have had no luck getting in touch with my medical insurance. Even though Eileen promises to help me with any paperwork the insurance might require for reimbursement, I had no idea what percentage, if any, my insurance would cover for non-reported out-of-network providers. I'm stuck trying to decide between taking the penalty but getting no service for it or going through with the appointment and risk having to pay for it out-of-pocket.

At this point, I'm very frustrated -- I studied this stuff for three years! I know how health insurance works! I can tell you the difference between HMO, PPO, FFS, and P4P, as well as the different incentives that they invoke, in a heartbeat! But when it came down to it, why don't I know how reimbursements and preferred networks work, and what I need to do to get it? I also found myself casting doubting glances at my doctor - was he trying to pressure me into paying him for the appointment without concern whether it would be paid for or not?

These thoughts are not the ranting complaints of an eager beaver who thinks a great deal but doesn't know how the world works (well, they kind of are, but I promise you I do have a point). If someone who is educated, knowledgeable in the theoretical workings of health insurance, and has a great deal of respect and understanding for health providers could, in one small incident, be made confused and doubting, what is it like for someone who sees health insurance as a black box, or a self-employed small business owner, or a cancer patient? Lack of knowledge and wondering, all the while desiring the relief of suffering, whether they can pay for improved health can make any patient anxious, interferring with the way they seek care and trust their provider.

Putting on my consulting hat, the next question is - so what is the solution? On the technology front, it's clear that even self-serve web-based tools designed to empower the patient to make more informed decisions can sometimes be confusing or even counter-productive if it provides erroneous or incomplete information. As an IT consultant at a large hospital, I see firsthand how out of hand and complex huge medical systems - whether it's EMRs (electronic medical records), electronic prescription signing, or insurance records - can get. As with any honest look at reality, we have no magic bullet solutions (see my previous post on health care IT - magic bullet or recipe for disaster?). As much of a cop-out answer as this is, we need to be both open-minded and cautious about adopting health care technology. The momentum forward for bring the health care industry up to the technological standards of pretty much every other privatized industry is an absolute imperative, but we can't do it blindly. There needs to be adequate research and planning before we shower money on EMR implementations and web-izing patient-provider information exchange (again, see my thoughts on health care IT and Obama's stimulus free-rider health care reforms).

Of course, this encounter was more than just a breakdown of technology. It microscopically reflects the fragmentation of our health care system. As a patient, my primary concern is my own best interest -- finding a provider whom I'll feel comfortable talking to about very personal experiences, who is willing to take the time to partner with me in my care, and whose expert opinions I can trust. Worrying about whether this provider will take my insurance, or worse yet, might slam me with charges for services that I had little control over due to my relative lack of expertise, should be the last thing on my mind. (The health care industry by nature is imbued with this imbalance of information, which endows the physician with the peculiar role of providing both supply and demand of medical services.) Envision walking into any doctor's office (primary care, specialist, eye care, midwife, dentist, acupuncturist, whatever), presenting proof of a single source of insurance (nationally funded with standardized levels of coverage, but operated by private insurance companies to ensure competition and efficient delivery), and knowing exactly what services will or will not be covered because you've checked the comprehensive federal website. You're able to clearly ask your doctor for certain services you know will be covered and have an actual informed converation. You walk away being satisfied with the results of your converation, knowing that you'll be able to use a web-based system to communicate to your doctor or his/her staff, manage your personal information, and access your test results. Most of all, you also feel assured that you won't encounter surprises in the mail or the next time you walk in the door. Oh, a girl can dream...

Epilogue

Things have a way of working out, even if it's in a twisted way. I called my health insurance to verify whether my optometrist was a vision provider and got an assurance that he is, even though Dr. Soss stressed over and over that he was tired of dealing with my insurer and only remained in their system for medical patients. For better or for worse, I'm just going to leave the bickering to my doctor and insurance company, file my reimbursement papers, and thank my lucky stars that I'm a healthy twenty-something who escaped relatively unscathed from the provider-patient-insurance entanglement (for now, anyway).