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The healthcare system can be a confusing place for someone who is well, let alone someone who is sick and in need of help. Oftentimes, health plan members do not know their benefits and can seek care in the wrong place; like the ER when the problem is not urgent, or outside their network, which means they may incur an expensive and unexpected bill. This confusion can cause delays in treatment and less than desirable outcomes; as well as an increase of cost to everyone involved–from the patient to the health plan itself.

Whether a patient, health plan administrator, or anyone in the healthcare system, it is important to learn about and avoid the following myths.

1. Finding a doctor is easy.

Not true. People often don’t know where to go or who to see. Many do not have a primary care physician (PCP) or even know that they should get one. Some physicians are very busy and are no longer accepting new patients, in order to provide the best care for their current patients.  Some physicians only take certain types of insurance. 

Challenges like these can lead people to see several different providers or different doctors for similar complaints before they get to the right one. This can create delays in treatment and duplicate medications, which can lead to less than desirable outcomes or complications.  Once found, a PCP will be able to help oversee their patient’s general wellness and coordinate efforts with other providers to promote the best possible health outcomes.

2. Continuity of care is a given at the hospital.

Several accreditation and safety oversight organizations have made great strides in reducing miscommunication.  However, patients need to champion their own health; paying attention and speaking up whenever needed to receive quality health care.  If many different health professionals are involved in care, it is important to be sure that each one is correctly informed.

When people go to the hospital, the first provider they see is who they assume will both help and stay with them throughout their entire hospital visit. In reality though, they may see 2 or more hospitalists during a single inpatient stay. Hospitalists are typically doctors or advanced practice nurses that work in the hospital to care for patients. This lets the primary care physician spend more time in the office to care for patients.  Hospitalists work on a scheduled rotation.  As one hospitalist goes off duty, another will pick up where the last left off.

A new hospitalist may want to change the treatment plan. This can make the patient uneasy. However, if the patient has a primary care physician, the care plan is continually monitored and directed by the PCP.  (Another good reason to have a PCP.)

Discharge summaries should be carefully read and compared to the electronic form printed by the doctor at the last visit. Good questions to ask- Are medications the same as those prior to admission?  Is one of the usual medications missing? Is there a clear plan of action to take upon leaving the hospital?  

If patients have more questions after leaving the hospital, they should contact the physician’s office; who sees the patients after discharge; or call the hospital unit where they stayed for clarification.

3. Providers actively manage health plan members with serious or chronic health problems.

The health system misses people with serious conditions all the time. This includes diabetics who are not seeing doctors or taking medications as they should, people recovering from surgeries who have forgotten to refill a prescription, or even those with cancer. 

Sadly, these problems can be amplified when those who have chronic conditions come from a household of lower income. Say for example one of these people is a diabetic, and chooses to buy groceries instead of using the money for drug co-pays. This person may only be seen after going into diabetic shock and rushing to the ER. 

This group of people can get into serious trouble, but are easily identified with healthcare modeling engines such as our own Poindexter and then assisted by our Nurse Navigators. The Nurse Navigators reach out to health plan members with gaps in care; helping them solve pressing problems, manage health challenges, and get the guidance to set goals to improve and reach optimal health.

4. Most physicians are paid for calls to patients between office visits.

The truth is, the system is mostly fee for service. Doctors usually do not call patients at home between visits. If someone finishes taking medicine and is no better, it is up to them to make the next move. This is how people fall into cracks in the system. If they don’t call the doctor to let them know that their prescription is used up and symptoms remain, they are on their own. This can lead to a recurrence of the initial healthcare issue or other severe problems. This scenario is one reason for preventable emergency room use, avoidable inpatient stays, and readmissions.

5. Seeing multiple physicians and providers does not create a communication problem.

The more providers seen; especially if they all order medications; the more complicated it can become. The worst case scenario is one where doctors prescribe different medications that have severe interactions.

If a patient’s doctor is allied with another doctor they see, and they both use the same electronic health records; the system works. But if other doctors are outside that health system, or the patient sees a specialist, or even travels, this information will not be in the electronic health records of the first group of doctors.

This is one of the prime benefits of Poindexter- it picks up ALL claims, nothing is missed. This allows health plans to see where breakdowns in the system have occurred, act on it, and craft an intervention that works.

6. Doctors only prescribe what a patient can afford.

Many patients have a mistaken impression that the doctor knows their economic situation. Nothing could be further from the truth. Doctors can see a new patient every 6 minutes, making it impossible to remember or even determine the financial situation of everybody.

Take for example a low income patient with a history of high blood pressure. The nurse takes the blood pressure reading and marks it down for the provider. When rushing through the day, the doctor may see a high blood pressure reading and order the first thing that comes to mind. This can be a new medication that they recently learned of and believe will work. What they may not be thinking about is whether or not the patient can afford this particular prescription.

Physicians, typically, do not know how a prescription might be covered by any of the thousands of different insurance companies. It would be unreasonable to expect them to. It is up to each patient to let the doctor know that they cannot afford the prescription, and would prefer a less expensive or generic brand if available.

Some people may think that their doctor won’t see them anymore if they don’t accept the prescription.  One of our Nurse Navigators recalls how a patient described his predicament-

             “My doctor knows that I still owe him $50. If I tell him I can’t afford the co-pay, he may not see me anymore. So when he takes my blood pressure and it is high, he assumes that I am taking my medicine and just orders more. I am too embarrassed to tell him that I haven’t even filled the first prescription.” 

There are ways to avoid this problem. Software systems (such as “Poindexter”) are now being used by physicians to tell them which medications were actually dispensed from each pharmacy and when for each of their patients.  It can also show the physician every visit or procedure, and medications that are dispensed by pharmacies.

If a software system like Poindexter is used, the provider will know when a patient has not been filling their prescriptions, and will have expanded information available in order to more effectively prevent and treat many medical issues. 

It can be difficult to navigate the healthcare system, but a little knowledge can go a long way toward avoiding delays, getting better care, and lowering costs for all involved.

Have any of these issues ever affected you? Post a comment below, and let us know your thoughts and experiences.

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