Medical Customer Service — getting worse

phonemonkeyCustomer service for most large businesses has gotten worse over the past few years according to American Service Index .  Of course, cable companies and cell phone companies are the worst but medical related customer service is also at an all time low.  This blog is not about phone calls to doctors and nurses but to insurance companies, retirement plans, ambulance companies, pharmacies etc.

You probably have your own horror stories (please add them in the comments).  Here are a few from friends and family:

  • The long term care insurance plan that repeatedly credited an account then send out a bill for the same amount.
  • The ambulance company customer service that changed billing codes to anything they thought would get a claim paid but could not send any documentation for a Medicare appeal.
  • The insurance company customer service that could not stop double billing for insurance coverage — “that’s a computer problem”.
  • The laboratory customer service representatives that only know the amount of a bill but not the service that was performed — “we only do what is ordered” —  they billed a urine culture but no urine sample was obtained.

One person had to call customer service over 20 times to get a medical billing problem resolved.

There are 2 major problems:

  1. customer service is outsourced — if the answers are not in the “computer” then you will get no help
  2. there is no follow-through.  Meaning, customer service says they will send a message to some department that will respond in “7-10 days”.  But, they never do and you have to call again.

So here are some suggestions for dealing with medical related customer service:

  1. Be prepared — have your customer number, billing number, a bill itself and other things you may need.  Many medical bills will have billing codes (CPT codes and ICD10 codes — look them up online if you can).  If your are calling for someone else (like a spouse or parent) — make sure that person can come to the phone.  A cool way to make this easier is to use Skype to include multiple people in a call if they live elsewhere.
  2. Be friendly, not overly stern.  Remember:  you are dealing with a person, possibly one that has little control over the company, don’t make their day worse.  You will get better results with honey than vinegar.
  3. Take notes as you talk.  Absolutely record the name of the representative, the date and what they tell you to do.  If possible get a phone number, fax number, email address and post office address if you need to communicate further.
    Depending on the urgency or the dollar amount in question (like over $20) then send a letter to customer service  summarizing your discussion and what still needs to be done.
  4. One strike and you are out:  If the problem in question is minor consider dropping the issue — your time is worth something. If you have to call back because you did not get a call or letter that was promised or the instructions you followed were wrong then demand to talk to a supervisor from square one — not another front line customer service rep.
  5. No strikes and your are out:  if the supervisor can not solve the problem or wants you to wait for a call-back or something to come in the mail tell them you need the phone number of the executive office or CEO in case the issue is not resolved since that is where you will call next.  Again send a summary of your discussion to the supervisor.
  6. If the problem is not resolved by the supervisor then call the executive office or CEO — you can almost always find the executive office phone number with a Google search for the business if needed.  Again, send a summary letter of the conversation.  Or if you can not get through send a certified letter with your concerns.

Pay the amount that is billed — but mark your checks “under dispute” if indeed there is a financial issue.  In general, resorting to legal action is a waste of time and money for disputes less than about $1000 since most legal fees will exceed that amount.

Complaints to the Better Business Bureau, the State Licensing Board, the State Attorney General or the Insurance Commissioner often get their attention.

If you are going to go nuclear, first send the CEO a brief letter with your complaints, the harm that has been done and what you want them to do — say you are serious and do not plan to drop the issue (no threats!).  Wait a while then send a second letter of what actions your are taking and do them – complaints to local or state officials or start legal action.

Medicare fraud is a serious matter, it should be reported as soon as it is identified.



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Medical Care and Control Theory

sweatshopPiecework maximizes human productivity.  Make more things, get more money.  Garment workers and physicians both have been paid under this system — it’s great if the payment per piece is high but miserable if the price is low.  Because piecework itself is no guarantee of quality inspectors were invented to reject low quality products.  Thus, the little piece of paper in your new shirt pocket “Inspector 23”.

What if you went to a doctor’s office and had to be inspected before the doctor was paid?  You had to have that little piece of paper “Inspector 23” to submit an insurance claim. That’s never going to happen but you get the idea.   The doctor is paid by the number of services but the service should meet a quality standard.

This example is just the tip of the iceberg.  Medicine is discovering process control without much input from the well established engineering field of process control.  It’s sad, and perhaps a little arrogant on the part of medical administrators and law makers, to ignore the extensive work on process control.  People do not like to be considered as little boxes in a system diagram — understandable — but a failure to think in this way is wasting trillions of dollars.  The time for change has arrived.

PieceworkThe black box of medical care is what happens with the doctor-patient interaction.  1) A patient enters the office, operating room or x-ray office then health care happens then 2) the patient leaves.  As it stands now the physician is paid by the number of services performed so the possible process control at points 1 and 2 are wide open.  Nothing is measured, nothing is controlled, and quality is not guaranteed.

Control Theory

Now, consider modern process control with 5 control points, a measurement point and feedback to control the input to the black box of health care.  What is in the black box?  Perhaps just one health care provider.  Or perhaps many health care providers. Instead of a black box it might be a grey box with lots of individual elements.

Parallel SystemPerhaps the box contains whole specialties or perhaps many hospitals within an accountable care organization across many states.

At the highest level of abstraction the feedback loop is intended to minimize cost but at the lowest level the feedback loop is intended to maximize quality.  To make sure throughput is maintained the providers need to be paid by the number of services performed but the flow of patients is choked off if quality is not adequate.

This is rocket science.  But, as Einstein says, a system “should only be as complex as needed”.  Health care is very complicated and at the present the garment industry is not the model the world should be using.  Simplistic ideas of supply and demand are not adequate to make a rocket fly nor to control cost in a health care system.

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Bleeding to Death at Nursing Homes — warfarin

NHadlsA story in Pro-Publica (7/12/15) and reproduced in the Washington Post highlights the problems with anticoagulants when given in nursing homes.  The graphic at the left shows the magnitude of the problem — lots of patients in nursing homes get these drugs.  The next graphic shows data from North Carolina pinpointing the main culprit: WARFARIN.

NHerrorsInNCWhat is going on?  Well, warfarin is a tricky drug because it changes the body’s system to make the blood clot.  Some people tend to clot too much (and get clots in the brain, a stroke, and some people get clots in the lungs, a pulmonary embolus).  Those people are at risk of death from too much blood clotting.  So, health care providers prescribe an anticoagulant to make the blood clot less easily.  Unfortunately, this creates a state where people bleed easily.  It is indeed a situation “between a rock and a hard place“.

Warfarin is one of the most common of the drugs for this purpose.  It has the advantage of an existing antidote and it is inexpensive.  But, it requires frequent blood testing to keep the anticoagulant effects in a reasonably safe range.  Providers must order the tests and must change the dose according to the results.

Thrombin inhibitors are a new class of anticoagulants which have the same bleeding risks and are expensive.  Their claim to fame is that blood testing is not needed.  They also have the disturbing quality of not having an antidote if bleeding starts.  Taking all this into consideration, most providers choose the older drug warfarin.

The reasons for excessive bleeding in nursing homes are:

  1. Prescribers (not the nursing home staff) fail to order blood testing when they should and fail to adjust the medication as they should.
  2. Prescribers fail to stop anticoagulants when the risk of falling exceeds the risk of blood clotting.
  3. Pharmacists for nursing home patients are not as connected to their patients as they should be — usually the pharmacist is the safety net for bad prescribing — sadly, they are out of the loop.
  4. RNs in nursing homes have the training to catch medication errors but function as administrators and are not on the front line of care.  Thus, like pharmacists they are not performing the safety net function they might in hospitals or doctor’s offices.
  5. Elderly patients are the most prone to adverse drug events — for them, if a side effect is possible they will likely experience it.   It there is a risk of bleeding they probably will.

What should be done:

  1. State certification organizations should develop guidelines that require nursing homes and their prescribers to have a protocol for anticoagulation management — not every prescriber can be allowed to invent their own method — that’s the mess we have already!
  2. Nursing homes should use electronic means to track anticoagulants and the adherence to prescribing protocols.  This is not rocket science, those protocols (evidence based guidelines) and computer programs already exist!  So, USE THEM.
  3. Proactive patients and families should ask about the protocol that will be followed for warfarin in the nursing home — if there is no protocol SPEAK UP — show them a copy of this blog.

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Say “NO” to antibiotics but then what?

cougherKudos to Consumer Reports for the article on the over-use of antibiotics “How to Stop a Superbug” in the August 2015 issue.  One of the most common reasons people see primary care doctors is cough.  And, as it turns out, most of those coughs should NOT be treated with antibiotics.  Of course, it does not mean they do not need treatment — just not with antibiotics since the cause is usually a recent viral infection.  Antibiotics do nothing for viral infections.

Doctors who inappropriately treat a cough with antibiotics often do so just to get the patient out of the office as quickly as possible.  Statements like “could be early pneumonia” or “I hear some pneumonia” or “you have bronchitis” is the politically correct version of “you will get over it, take this pill and don’t bother me”.

So what is going on?  A virus irritates the lining of the bronchial tubes.  The tubes become inflamed and overly sensitive, causing the symptom of coughing.  Coughing is bothersome, it keeps people awake at night, makes noise at work and after a while it hurts the ribs and chest — it’s super irritating — please get rid of it!

The bottom line is that a virus infection causes a temporary form of asthma.  Doctors have hesitated to make that diagnosis because once you say “asthma” it is like a life-long diagnosis — in fact, it could have been a reason for an insurance company to deny coverage in the past.  So, by avoiding the “a”-word adequate treatment is not offered.  Anti-asthma treatment really works! and it is almost always a temporary treatment (unless the person really does have typical asthma).

Why a researcher would do such an experiment is not clear but they have compared the benefit of antibiotic treatment versus an asthma inhaler for “acute bronchitis” and found the inhaler works better — duh — treating a virus with an antibiotic is a placebo treatment.

Cough after a viral infection, particularly influenza, can last a long time, sometimes months, even though the virus itself is gone.  And, when people have a long-term cough other diseases need to be considered.  A cough that lasts for more than a few weeks usually needs to be evaluated with a chest x-ray as a precaution.

Many times a long term cough is the result of ineffective treatment — the failure to prescribe adequate inhaled medication to begin with.  Sometimes, it is the failure of the patient to have the prescription for the inhaled medication filled (it’s expensive) and sometimes it is a failure to take the inhaled medication correctly.

Very few doctors explain how to take an inhaled medication — it just takes too long, and they expect the pharmacist to do that.  Sadly, the pharmacy tech who hands out prescription has no idea how an inhaler should be used — and the pharmacist is not much better.  Proper technique (click on the link) is critical for the medication to work.

What inhaler is best? — there are several to choose from.  Check your insurance formulary for a combination product containing both a steroid and a bronchodilator.   There are no generics in this class of prescription drugs and that is another story!  Some choices include Dulera, Advair, and Symbacort (there may be others depending on what country you live in).

Again, thanks to Consumer Reports.  But, they did omit the obvious question for a cough:  if you don’t take an antibiotic for a cough, exactly what do you do?  If it’s mild, cough-drops are helpful, but if it is a bigger problem an anti-asthma inhaler is often a huge help.  Be proactive, tell you doctor you don’t want an antibiotic for your cough but you do want an asthma medication — bring this article with you.

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Ambulatory Surgery Centers — quality from the patient standpoint

ascwaitingPatient’s who have minor surgery at an ambulatory surgery center (ASC) don’t really know what to expect.  And, after the experience they often wonder  whether they received high quality care.  The basis for thinking the quality was good is usually the perception the staff was friendly and the fact the patient indeed survived to ride home in a car with a friend or relative.

There are more than just those 2 dimensions of quality.  What should an informed consumer watch for?  Or, more likely, what should family members who accompany the patient look for?  After all, the patient is a little anxious before surgery and often sleepy after surgery, mostly concerned about getting to the car.

Here is how a smooth high quality ASO interaction works:

  1. Primary care physician contacts the surgeon about the patient by phone or secure email to see what steps need to be taken for a possible outpatient surgery — like treatment of carpal tunnel syndrome.  And, the surgeon gets information about the patient’s other health problems.  Appropriate tests are ordered and an appointment with the surgeon is made within about a week.  All records are electronic and made available to the surgeon.
  2. The surgeon has a clinic visit with the patient.  The nature of the surgery is explained to the patient both verbally and with diagrams.  The surgeon states whether they feel the proposed surgery is reasonable under the circumstances and describes what the surgery entails from their standpoint.  But, no decision is made by the patient at that point.  The surgeon uses a shared decision making technique.  Meaning, the patient is given literature and internet links to review.  Also, a link to all previous patient satisfaction surveys about the same surgery are provided to the patient.   Plus, a packet with all the documents that must be signed.  Staff review the patient’s insurance and estimate for the patient ALL the out of pocket costs of the surgery (surgeons fees, ASC fees, devices, and drugs).
  3. Later, perhaps a couple of days later, the surgeon calls the patient, questions are answered and a joint decision is made about whether to proceed with the surgery.   Also, at some later time the patient talks to the anesthesiologist on the phone and can ask questions about anesthesia issues.
  4. If the patient wishes to proceed the necessary documents are signed (on paper or electronically) and an appointment for surgery is made.  The patient takes or sends the documents, including operative consent, HIPPA forms, etc, to the doctors office. The primary care records, the surgeons records and the documents are made available to the ASC.   No additional forms need to be signed or completed at the ASC.
  5. If there are questions about medication management or other medical issues another phone call or email is exchanged with the primary care provider.  The patient should never be a messenger asked to get information or ask questions about medications from the primary care provider.
  6. Required pre-operative examinations are performed by the surgeon or assigned physician assistants in a timely manner.
  7. The patient arrives at the ASC at the appointed time, no additional paperwork is needed.
  8. The patient is taken to a personal pre-operative room, not to a public waiting area — privacy of outpatient surgery is important.    All patient charting is done with a computerized system.
  9. The nurses, anesthesiologist and surgeon meet with the patient and family.  Any last minute questions are answered and post-operative instructions are discussed with the patient and persons taking the patient home.
  10. After appropriate preparation the patient is taken to the operating room and after surgery returned to a recovery room, hopefully the same room they started in.  The surgeon and anesthesiologist meet with the patient and persons taking the patient home to relate the outcome of the surgery and to repeat the post-operative instructions.  Written instructions with a follow up appointment date and time are given to the patient.  A phone number answered 24 hours per day is given to the patient for any problems or questions that arise at home.  Telling the patient to go to the ER for all problems is not acceptable.
  11. No patient should feel they are the last patient of the day and must leave because the ASC is closing.  The ASC must stay open for several hours to accommodate all needs of that last patient of the day.  Minor complications, like urinary retention, should be resolved by the ASC, not an ambulance transfer to the ER.
  12. The surgeon sends the operative report electronically to the primary care provider and sends a letter to the patient about the diagnosis and results of surgery.
  13. Later in the day or the following morning someone at the surgeons office contacts the patient to see how they are getting along, to answer questions and prescribe additional medications or treatments if needed.  The date and time of the follow-up appointment are again reviewed.  The patient is asked to participate in a patient satisfaction survey.
  14. The patient fills out the satisfaction survey on paper or on-line.
  15. The patient returns for the post-op visit with the surgeon as scheduled.  The final diagnosis is discussed with the patient and further instructions are provided.

Well, is that how your outpatient surgery went?  If yes or if no, leave a comment.  What was good at your ASC and what was bad?

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More Clinic Visits for Diabetics — use the phone

stringphoneJune 3rd 2015 Kaiser Health News reported the ACA seemed to cause more provider visits for management of diabetes “More Patients, Not Fewer, Turn To Health Clinics After Obamacare”.   This is both good and bad.

The “good”:  more attention to a patient’s condition is likely to result in better diabetic management, fewer complications, fewer hospitalizations and longer life.

The “bad”:  since clinic visits can be billed to insurance, clinics make appointments and make money for each visit.  The payment for visits rather than outcome is expensive and a known problem in US healthcare (fee for service).  Diabetes can be managed over the phone in many, if not most cases — but there is no money for the provider in that approach.  Phone care has a much higher value for the healthcare system and the patient; but, low-cost high-quality (high value) care is not getting the incentive.

The care of diabetics is further compromised by the pharmacy.  A key piece of equipment for a diabetic is a glucose meter.  The manufacturer almost gives away the meter so they can make huge profits by selling the disposable test sticks.  The sticks are not interchangeable, not generic, sold in small lots, each lot sold with a co-pay, each lot requiring a visit to the pharmacy, and the use of gasoline to make the trip.  If you don’t have much money the speed-bump turns into a mountain.

The solution:  every few years mandate a generic test stick that manufacturers of glucose meters must support.  “Uncouple” the meter maker form the test stick maker.  And, sell the sticks in lots that last for at least 90 days, and that are sent to the patient by mail.   Adjust the payment to providers so that they must contact diabetics by phone to adjust medications at least 2 times per month in order to bill for a medium or high level clinic visit.  Also, each provider must obtain patient satisfaction data to prove the adequacy of service.


Addendum:  Here is a link to an interesting court case about glucose meters

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Warning: Price could cause ulcers — CMS drug data

purplepillThe purple pill tops the list of the most expensive drugs for government health programs in 2013.  No, your first reaction to blame the government is wrong — the drug is prescribed by health care providers — and, the government is prevented by law from negotiating drug prices.  Why is this a problem? –there was a perfectly fine OTC generic substitute available in 2013 at only 6% of the cost.

WHAT???  Prescribers wrote prescriptions for a drug that could have been substituted by an equivalent drug and saved 94%.  OK, at the margins of the argument, at the fringes of reality, at the level it makes no clinical difference, big pharma says it might not be a perfect substitute.  A good example where the “perfect”  is the enemy of the very good.

But, how could prescribers and patients have the wool pulled over their eyes? — fantastic marketing.  And, by the way, if you take this drug, send me your name, address, social security number, and bank account number,  I have a nice bridge to sell you.brooklinbridge

The magnitude of the problem became crystal clear when CMS published prescription data.  The following data is widely reported from CMS as the spending on drugs through Medicare’s Part D prescription-drug program in 2013:

Rank Brand Name Generic Name Number of Claims Cost in Billions
1 NEXIUM ESOMEPRAZOLE 8,192,362 $2.53
28 OMEPRAZOLE OMEPRAZOLE 32,250,368 $0.64

Omeprazole is a very good substitute for Nexium for heartburn and reflux.  Despite the cloud of industry generated studies many pharmacists say the two drugs have equal effects.  As the table above shows omeprazole was prescribed 4 times as often as Nexium but the providers who chose Nexium created a vastly larger and unnecessary cost.  Why Nexium is even be on the Medicare Part-D formulary is a mystery.  Who pays the bill? — taxpayers, of course, and the patients who paid a co-pay higher than the full cost of an equivalent.

In 2015 Nexium became an over the counter drug (OTC) and just as you might suspect it now costs about the same as OTC omeprazole — about $32 for 56 pills (at Costco) rather than $300.

Where is the oversight?  Where is the cost control?  Why is US healthcare so expensive?  Need more examples? Just look at the other medications on the list.

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