Thursday, May 15, 2008

I Have A Good Doctor

I've heard it said that the good doctors are the ones who don't take insurance. The theory is that if a doctor is skilled enough, he or she can fill up their practice with private-pay patients without having to rely on an insurance panel. I'm not sure this holds up in regions where there are so few specialists that anyone could have a full practice without taking insurance. Regardless, it inspired me to think about how to judge the quality of your doctor, particularly when you have no health care training.

Patients aren't the only ones concerned about quality medical care. Professional organizations have ways of ensuring competence and insurance companies are also now taking steps to measure treatment outcomes and other parameters of care. The interesting thing is that each of these three groups use different measures.

Patients look for things like interpersonal skills, communication style, the amount of care and attention given during appointments and recommendations from friends or family. They may also consider things like convenience (appointment availability or location). Since the invention of the Internet patients can also now go to online physician review sites and searchable databases.

Professional organizations encourage people to consider things like physician training and experience, board certification, participation in continuing education and the absence of malpractice settlements or disciplinary actions.

Insurance companies now are starting to institute "pay for performance" indicators of quality: timeliness of appointments, adherence to practice guidelines, treatment outcome measures and patient satisfactions surveys.

So, does any of this stuff actually guarantee you'll get good care?

Of course not. Personal impressions and outcome numbers don't tell the whole story or may be misleading. Doctors with terrific interpersonal skills can give lousy care and still have loyal patients who defend their bad practices. Doctors who kick small dogs and are mean to their spouses could still be good technically. I happen to think my ophthalmologist is the best thing since sliced toast and I'm willing to wait weeks to get an appointment with him, but I can only trust that when he scans they back of my eyeballs he's seeing what he needs to see. I'd be willing to bet that if I had a rare or serious disease I'd want I doc who was the best (or at least great) at dealing with that disease and I wouldn't care if the the insurance company told me that half his patients died---the mortality rate for my weird serious disease could be 80%. He probably wouldn't take insurance anyway.


Dinah said...

No one takes my insurance. I don't take my insurance. Oh, the pediatrician takes my insurance, and he's wonderful. The dentist gives me an envelope to mail the statement in with, but I have to provide the stamp.

Rach said...

That's why I live in Canada... (actually that's not why. I was born here and never left - although I'm planning to move to another country with Socialized medical care).

I'll take my shrink's hour-long waits in the waiting room; month-long waits to get a referral to a specialist, crazy fees for letters, phone calls and other stuff, but I know that I can call and leave a message and still get an appointment the next day - and I don't need to bring my wallet, or my chequebook with me.

Anonymous said...

I pay something like $700 a month for Blue Cross (self-employed) insurance, but have ended up with 3 doctors I pay 100% out of my own pocket all of whom are expensive. I am in a large urban area with about the highest concentration of doctors anywhere in the country but the elite here don't take insurance. All my docs were referred. My GYN (at $350 a visit) and endocrinologist (about the same plus lab) both teach as well as practice. I never wait for my psychiatrist. He's absolutely punctual about starting on the hour and ending at 10 of. The GYN is pretty good about it (she does not do O.B., only GYN) but the endocrinologist might as well be delivering babies for as punctual as he is, PLUS he has a lousy "bedside manner" but I put up with him because he's brilliant.

Battle Weary said...

If the "good doctors" are the ones that don't take insurance, what is the message that is being sent to the millions of people who can not pay a doctor out-of-pocket? If you don't have a heafty bank account, you get substandard care? There are millions of Americans that work hard, pay their bills, and have insurance; but would not be able to afford to see a doctor without insurance. If I needed to see my doctor once or twice a year, I could probably pay fee-for-service, but that is not my reality. I have diabetes and asthma. I see my doc every three months, and have labs drawn every three months, for the diabetes. The asthma is less predictable; I may go 9 months without seeing her, then see her 6 times in one month. Add to that any other problem that may crop up, and meds...maintenance inhalor every month, emergency inhalors, diabetes meds and testing get the idea. Without insurance, I'm going to have a hefty, very slowly paid, ER bill, and a lot of diabetes complications that I will again not be able to get treated! Let's not even bring pdoc and THOSE meds into the equation! :P

Anonymous said...

I struggle with the idea of figuring out who the 'good' or 'elite' doctors are, in addition to knowing when to use them.

Technically you could say I was an 'elite' doctor because I don't take insurance, I teach on two faculties and I have a busy in-demand clinical practice. (Bear with me co-bloggers, I know I'm being ridiculous!) But I don't think of myself that way and I doubt my prisoners do either.

Some folks want 'the best' for everything---automotive care, home renovation, medical care, whatever---with the thought that you save money in the long run by paying for the best up front. Some folks need super-specialists because they have rare or difficult-to-treat diseases. There's validity to both approaches.

The whole thing reminds me of a story from my medical school days at a teaching hospital, when a woman insisted that the nationally-known department chair obstetrician do her newborn son's circumcision. Now, traditionally circumcisions at this hospital were done by residents. After rounds the elite attending told the resident, "I haven't done a circumcision in ten years. Go ahead and do it." The baby got better care by not going along with the request for 'the best'.

I don't have any answers here, but I do share Battle Weary's concern about giving the 'best' care even to those who don't pay out-of-pocket.

Roy said...

BW, I don't think it's so much about sub-standard care with docs who take insurance. I think it's more about what Clink says, about the "perception" of being "good"... which really only means that the doc can get enough private pay pts to fill up her desired hours.

Her pts may be willing to pay out of pocket, not only for "good care", but probably more so for things like:
-bedside manner
-waiting time for appt
-recommendation from friend/family

Unfortunately, insurance companies have made it so difficult to work with them (either on the pt side or the doc side), with their forms and procedures and denials and appeals and delayed payments, that they are now seen as an unwanted middleman, and are jettisoned ASAP.

Many are now going for inexpensive, high-deductible, so-called "catastrophic" policies, paying out of pocket for routine care and having insurance step in for expensive hospitalizations and such.

But I don't think that those who take insurance are "substandard"... just either more efficient or more tolerant of dealing with the middleman.

Anonymous said...

A quote from Albert Einstein:

"Not everything that can be counted counts. Not everything that counts can be counted."

IVF-MD said...

A quote from Albert Einstein:
"Not everything that can be counted counts. Not everything that counts can be counted."

How about the opposing view? That if something can't be measured, it can't be studied scientifically.

The reason it's so difficult to quantify what makes a GOOD doctor, is because there are many different definitions. Some examples of what constitutes a good doctor include the following:


1. ABILITY: Provides the patient the highest odds of solving their presenting medical problem (ability to diagnose and choose best tx)
2. TRUSTWORTHINESS: Presents the lowest chance of cheating or mistreating the patient for his/her own personal gain (etc unnecessary surgery)
3. DILIGENCE: Pays careful attention to being thorough (not careless, not neglectful)
4. INTERPERSONAL SKILLS: Provides the best experience for the patient (best bedside manner, accessibility, ability and willingness to calm patient's ears)

Each of the above can be loosely rated, but there are many inherent flaws in the methods we have to try and quantify the above.

This is by no means limited to doctors. Have you ever tried to decide on who is a good accountant, lawyer or plumber? :)

NeoNurseChic said...

I am happy to say that for me, I have the best team of doctors possible for myself, and all except the psychiatrist take insurance. I don't know if he takes insurance at all, but I'm told that my brand of insurance has a very crummy mental health plan (Magellan, anyone?) that is difficult to work with, so no doctors take it. Roy, I would have to say that insurance in the psychiatry world is a totally different beast than insurance in the regular medical field's world, and this angers me to no end. A psychiatrist, a medical doctor, who trained at the same facilities as every other specialist, is treated sub-standard by the insurance companies. It isn't covered by the traditional medical insurance, but some mental health policy, where they lump all of psychiatry/psychology/etc together under one branch and place so many limits on it that it's not even worth using! Thank goodness my psychiatrist charges me what he does, or I could never have afforded to see him!

Now - I personally believe that all the doctors I see are "the best" I could have for that particular ailment. Are all of them the most world-reknowned for their specialty? No, but some are pretty close up the totem pole. But they are all experts in their field, and I personally put a very high value on expertise in one's own field as well as bedside manner. I really don't want one without the other! Some people say when it comes down to it that they'd rather have the brilliant doc than the one with good bedside manner. Uhuh - I want BOTH - and I won't settle for less because it's MY choice. A brilliant clinician might be able to cure all my ailments, but if I cannot relate to them or they don't appear to "care" about me, then I really don't think I'll get better in the end because I truly believe that you can't just treat a disease - you have to treat a person, a human being. I think people do better, medically, when the entire person is treated - and if part of that is being treated with respect and kindness by a medical doctor, then I think that's just as important as their clinical excellence. NOW - I wouldn't want a doctor who was excellent with bedside manner but lacking in clinical excellence, either. I know I live near a large city, and I have access to a plethora of very very good and skilled doctors, so I also have the choice to choose who I want to see. I also have insurance that allows me a pretty fair flexibility when choosing my outpatient doctors, although very limited when it comes to surgeries and inpatient stays. All that being said, the hospital where I'm required to have surgery is the hospital I would choose to have most of my surgeries anyway, and where I did just have surgery 3 days ago by a neurosurgeon who I consider to be first class.

Ultimately what I'm saying is that I don't want one thing or the other when it comes to clinical excellence and bedside manner. I want both. I'm lucky that I have found doctors who meet this criteria for all of my many needs, although it took some degree of time to build up this "team" (who don't even know they're all on the same team, but that's a whole other issue that I won't get into here!). I am also lucky that all of these providers take insurance because I would be unable to see someone who is considered "the best" but doesn't take insurance unless they did what my psychiatrist has done, which is basically make little or no money for seeing me out of the kindness of heart. haha I've been referred to some of these doctors who are supposed to be "cure-all" for various ailments I suffer with but don't take insurance, but I've never ended up going to any of them - I wouldn't have been able to see them for the amount of visits necessary at the cost required, so it would just be a waste.

What's interesting is that not that long ago I was on the Health Grades sites rating one of my doctors. I was the 2nd person to rate him, and based on the end result, you could tell that the other person rated him 100% negatively, whereas I rated him nearly 100% positively. And I think this is one of the best doctors I've ever had. Just goes to show how much a matter of perspective it is. I wish I could interview the other individual who filled out the rating and ask why he or she chose to rate the doctor so negatively. What I might overlook in order to see the things I want to see in someone, someone else will focus on. For example, I wait long amounts of time to see some of my doctors - but I know that once they see me, they will spend a lot of time with me, so it's worth it. I'd rather wait a long amount of time and then have quality time with the doc, rather than being exactly on time but be rushed through the appointment. But those doctor, hospital rating sites out there now value punctuality. Personally I think that this is a matter of perspective - punctuality is important, but it is more important the quality of the time the doctor spends with me. Perhaps the next person places a differing value on the same issue.

Pay for performance is scary because not everyone values the same things. These companies think they can set standards that make up a "good" doctor or hospital, but not everyone sees it the same way! I'm on my hospital's Q&R committee, and I work with these numbers quite frequently, and I can say that it just depends on the person. How can 2 people who received the same care both say that it sucked and it was awesome? It's all a matter of perspective, and it can never be quantified in an accurate way.

Take care,
Carrie :)

Anonymous said...

I started "shopping" for doctors when my GYN wanted to do a complete hysterectomy for endometriosis. I found a great doc who took the time (5 to 6 hours) to carefully remove the endometriosis yet leave most of my female tract intact. After he retired young (when he married a rich woman) I tried a recommended GYN who I asked to test my thyroid hormone because it had been dropping. She did bloodwork but when I called the office I was told my bloodwork was "fine". I insisted on knowing my TSH VALUE and kept being put off. After 3-4 calls I found out that the GYN had forgottne to test my TSH or other thyroid hormones and had just a standard blood workup! That's when I REALLY started shopping for a GYN. A friend recommended my endocrinologist and he recommended my GYN. A psychologist I know recommended my psychiatrist. The psychiatrist I used before my current psychiatrist was the one who never looked at me and misquoted what I said to him ans saw me for 10 minutes, but he was GREAT with insurance. All I owed was a $15 copay and he did all the work. I'd rather pay and actually get good care. My deductible is $2,500 though they discount every medical fee. If a medical bill is $500 they say that the "reasonable and normal" fee for that service (maybe in Kansa but not here!) is $80 and give me an $80 credit towards my deductible so it's almost impossible to ever meet the deductible.

Anonymous said...

The doctor rating sites are so silly. I could go on and rate a doctor I have never seen. An ex spouse could leave a nasty rating and a doctor could leave a wonderful rating for himself. They are a pretty useless tool because they are not controlled.