Who is your doctor?
That should be an easy question to answer. It’s not.
Most of the time, it is a fairly straightforward question. A person’s primary care provider (PCP) is responsible for quarterbacking the individual’s care pathways and is supposed to be looking at the big picture as well as the day to day flows of a patient. For most people who see their doctor and thus have a claim, the person that the claims analysis system says is their PCP and who they say is their PCP is the same individual. But not always.
There are a couple of cases where there is significant areas of conflict. The first is when a person indicates that Provider A is their PCP but they have been seeing Provider B, who fits normal PCP criteria, numerous times in the recent pass. This could be driven because their is a slight misclassification where Provider B is acting as a specialist. That is not too uncommon for Ob-Gyn and some infectious disease specialties where a provider will be dual classified as both a specialist and a PCP. Geriatricians are slowly becoming more likely to be dual credentialed as a PCP and a common specialty like cardiology.
Another case of confusion is when a person does not routinely see a provider for primary care. My dad did not see a PCP for most if not all of my childhood. My wife has not had a PCP appointment in years as she gets her only regular interaction with the medical system through her OB/Gyn or at the urgent care for an annual flu shot. These are not profoundly unusual situations. Most people in most years barely touch the medical system. Finally, there are cases where people are in flux for their care patterns where there is a major discontinuity in their utilization. This can be done through either an insurance switch or a disease burden transition.
A new study** highlights the problems of trying to guess who a person’s doctor really is.
The study sample included 15,624 patient-years from 3658 older adults with diabetes. Agreement was higher for algorithms based on primary care visits (range, 78.0% for majority match without a tie breaker to 85.9% for majority match with the longest time from first to last visit) than for claims to all visits (range, 25.4% for majority match without a tie breaker to 63.3% for majority match with the amount billed tie breaker). Percent agreement was lower for nonwhite individuals, those enrolled in Medicaid, individuals experiencing a PCP change, and those with >10 physician visits.
85.9% is pretty good but the last 14% is a major policy problem.
Why does this matter?
As we move towards alternative payment methodologies, accountable care organizations, global budgets, capitation systems and other provider side risk carrying payment methods, the question becomes important. Who is the doctor financially responsible for and who is at risk of a major claims blow-up? There are three major error types from a provider group perspective
The first is a patient is assigned to a group incorrectly. The group is getting paid for the patient’s care but they are not in a position to influence the individual’s care as they don’t see the patient on a regular basis. They will not complain too loudly if this is a patient who retrospectively and prospectively looks to be a highly profitable patient who uses very few services. If the patient has a chronic condition which requires expensive and chargeable to the global budget treatments, the practice group will scream.
The second error is when they routinely see a patient and get paid for that patient on a fee for service basis but the patient is not “their” patient. The provider is performing the role of PCP in most cases but is offloading performance risk to another practice. Here they will fight to get the patient re-assigned to their risk bearing entity if the patient is a probable profitable patient. If the patient is likely to be a time, cost and risk sink, the treating physician will not seek patient responsibility to be transferred to them if they can get away with it legally and ethically. This is effectively the mirror of the first scenario.
Finally, there are the patients who no one knows anything about. They are new to the data systems because they changed providers or they changed insurers or they just don’t go to the hospital. Providers will push back on assignment if they are being held to quality metrics where these people make up part of their denominator and there is absolutely no data on them. They will also push back if they are panel slot constrained and these ghosts occupy panel slots that the provider thinks they can fill with more claims paying individuals.
85% match rates are pretty awesome, but the study is using a single large academic medical center’s data set and consists of traditional Medicare patients. Academic medical centers tend to have fairly deep data sets as they have multiple specialties and usually multiple PCP clinics under the same roof. Smaller medical practices will have fuzzier and shallower data. Medicare patients by default are high touch patients. Being old means being in touch with the medical system. Younger, healthier and more transient populations will have fewer and less frequent touches in any given look-back period.
So who is your doctor?
¯\_(ツ)_/¯
** Dugoff, E. H., Walden, E., Ronk, K., Palta, M., & Smith, M. (2017). Can Claims Data Algorithms Identify the Physician of Record? Medical Care, 1. doi:10.1097/mlr.0000000000000709
Sarah in Brooklyn
Gah! Who’s!!!!! (Sorry for being an asshole.)
dr. bloor
Is this insurance company speak for “who knows, but we’ve off-loaded the risk of a high-utilizer running loose in the wild?”
Ruviana
@Sarah in Brooklyn: I agree! Who’s!
satby
Looks like just another reason to reduce the profit motive for health care as much as possible. I’m probably in that 14% because I don’t go to the doctor unless I feel the need, and I last felt the need about 6 years ago when I ruptured the tendon in my shoulder.
m0nty
Yes yes, grammar Nazis. I don’t give a darn is our shortstop.
Spanky
@Sarah in Brooklyn: Yeah, I was going to say (being an asshole myself) ” Yeah! ‘Whose your doctor?’ is a difficult question to answer!” So thanks for saving me from looking like an asshole, which is what I am.
Now whats the question again?
Hunter Gathers
I have a soft spot for the 2nd, really like the 12th, but 11 is my favorite. He had me at fish fingers and custard.
m0nty
@Spanky: no, Watt’s on second.
Spanky
Also too, I think I have a lot of company in saying that I don’t have a PCP at the moment. Even in a relatively wealthy and politically favorable (to doctors) environment like Maryland, PCPs are getting out of the business – or at least those I’m familiar with are. Is it just that after so many years some either get fed up or worn out? Dunno, but I don’t see a lot of newly minted MDs going into the Primary Care business around here.
ETA to point out that I would rather have a PCP than not, rather than simply choosing not to.
Ruviana
You fixed it! Thanks!
Spanky
@m0nty: Wellll, I don’t know ….
cervantes
We did a similar thing with Medicaid in Rhode Island, and the result was even worse. The main reason is that a lot of Medicaid patients are in managed care, and they are assigned an official provider — but half of them go somewhere else. Another problem — all the people in the cited study were over 65 on Medicare. In the Medicaid population, you have a lot of reproductive age women. If they get prenatal care, they’ll have 18 visits to an ob-gyn, and the algorithm assigns them to that person, but their PCP is somebody else. You cannot assign people to a PCP by claims data, it doesn’t work.
FlyingToaster (tablet)
@Hunter Gathers: Fourth. Without question.
cervantes
@cervantes: (The paper is currently under review.)
rikyrah
I helped my mother deal with her diabetes, and to be honest, her endocrinologist pretty much became her primary care doctor. That’s who she saw the most.
I have a primary care doctor. I don’t dislike her, I just really liked the primary care doctor that I had before her.
jacy
@Hunter Gathers:
11 is my favorite too! We are in a quiet minority.
I have a GP, an oncologist, and OB/GYN, and endocrinologist (actually 3 of them). At one point I had a team of 9 doctors that I saw regularly. That didn’t count the surgeons. Oh, and a clinical therapist who I see once a week. Who did I see most often? Depended on the week.
cervantes
@rikyrah: Yes, when people have a chronic disease the specialist often starts to act as PCP. This is what usually happens with people with HIV, for example. The ID specialist becomes the de facto primary care provider.
Johannes
Capaldi. Then Davison, then McCoy, then Pertwee.
I love the rest, mind you, but those are the top 4 for me.
Ruckus
I have a PCP. They are necessary to refer me to any specialist. Of which I see a few. They are necessary for me to get a regular check up. And not one of them is an MD.
Feathers
I’ve got this issue now. I’ve finally gotten real coverage through the temp agency for the contract position I’m on. Now I’m getting calls from the insurance company offering me a gift if I go through some sort of screening within 90 days. But I don’t know if I want to or should. I’m basically healthy but obese and with a history of mental health issues. Do I hide or do I try to use the insurance to get the help I need to try to be able to keep this job?
Emma
@Johannes: Bite your tongue: Baker, Eccleston, Tennant, Davidson (the order depends on the moment). Although Pertwee is in a class of his own.
To the matter at hand: since I am in the final stages of a five year post-surgical protocol for breast cancer, my clinical oncologist has to clear most every medication I take. So although I have a primary who does my annual checkup and takes care of most my regular needs, it is the oncologist that controls the treatment.
raven
We are still in limbo on our appeal to BCBS for the broken wrist my wife suffered “out of network”. We thought we were saving them, and us, money by going to urgent care in Florida. It turns out BCBS thinks that, even though the X-ray faculty they sent us to was in the same building, that an X-ray was not part of emergency care. They took the pictures and the attending physician (or NP) sent us to an orthopod for further evaluation. None of that was covered either! I wrote a long appeal and just got the denial. We have never gotten a bullfrog anyone so I am tempted to just let it go.
Yutsano
@Johannes: Davidson, Tennant (his birthday was yesterday BTW) McCoy (a delight but never really got a chance and Ace was amazing) and I do actually like Matt Smith.
Woodrowfan
@Yutsano: McCoy was great once they replaced Mel with Ace.
The Moar You Know
Have a PPO. A good one. The best GP doctor in that system I’ve run across is someone I would not let work on my dog. So no PCP. In an area with one of the highest concentrations of doctors in the whole freakin’ world, I can’t find a good one on Gold Plan PPO. Still better than Kaiser was, marginally, and that margin costs three times as much.
Have a family friend who is a doctor and rich enough (and has a high dollar enough clientele) that he does not take insurance. Any insurance. And he’s the guy who I usually see first, because like my vet, he actually gives a shit, follows up, and is competent. So my doctor visits cost a lot more than they should, but I don’t waste money or time trying to get properly diagnosed and referred, if needed, to a specialist.
That’s going to be the future for those who can afford it. I can afford it for the next two to three years, because my friend is retiring soon. I think pretty much everyone else is fucked, as I will be in a couple of years.
eldorado
i’m just about to go to an appointment with my (new) family doctor. this is the first time i’m going to see the same doctor twice in i don’t know how many years.
Keith P.
I couldn’t tell you who my PCP is, and I get asked all the time. I’m on dialysis, so I really don’t go into offices much (I’m really supposed to go visit my nephrologist and my cardiologist, although the former visits me every 2-4 weeks) I see all specialists…the closest I have to a PCP would be my nephrologist’s nurse-practitioner, who I see every week (and I have immediate access to nurses 3 days a week during treatments)
It periodically comes up, say, when I broke a toe or have a skin rash. But even for things like the flu, I wouldn’t make an office visit; rather, the dialysis staff just run an IV of medication right into my lines.
Tazj
@raven: That sounds crazy. Did they expect you to go to a hospital ER?
I hate going to the doctor and try to avoid it as much as possible. I can’t entirely avoid it though because of my family history of breast cancer.
I’m waiting on an oil change for my car and thankfully the men around me have stopped talking about Trump.
Adria McDowell (formerly Lurker Extraordinaire
@Ruckus: Same here. Only my PCP is a DO, and I don’t go to too many specialists, or only go to them once a year (GYN, derm, allergist twice a year). The only specialists TriCare doesn’t require you to go through your PCP for are eye doctors or mental health specialists.
zach
“So who is your doctor?”
Honestly, Google. I’m a scientist and I can read the scientific literature (and have access to it). If I have anything complicated I check Google, then go to the doctor and pretend that I didn’t. I realize doctors roll their eyes at this, and that for every one person who can kinda adequately read the literature there’s a hundred who will be misled by quackery. But the few times I go to the doctor in my life with something vaguely exotic it’s saved me to have done my homework first.
amygdala
@cervantes:
The challenge with this is that depending on what the chronic illness is, the specialist may not be properly trained to provide primary care, which is a hell of a lot harder to do than is broadly appreciated.
To use your HIV example, in the clinic I worked in the younger HIV docs shifted back and forth between the complexities of HIV meds and managing mental health issues, adjusting thyroid meds, and health care maintenance (just to toss some examples out there) pretty easily. Some of the older docs, who knew everything–and I mean everything–about every HIV med ever put to human trials weren’t so great at managing hypertension.
I think we need new models for integrating specialty and primary care for patients whose chronic specialty-related medical issues predominate. Nephrology, as has been noted above, does this well, and HIV medicine is getting on the bandwagon, too. But I think it’s because they’re all internists, and they learn primary care during residency.
I struggled with this in my own clinic. I’d always try to make sure my patients had PCPs, for a whole lot of reasons. Even if I were trained to do primary care, the clinic space, schedules, and staff aren’t set up for it. Our clinic met three days a week; what happens if someone gets an ankle sprain on one of the other days? Thanks to Joint Commission, we weren’t allowed to do glucose checks because it was a specialty clinic.
Even for stuff I know how to do–keeping an eye on bone density in someone who’s on first gen anti seizure meds, for example–a lot of insurers wouldn’t accept a bone densitometry referral from me. It had to come from the PCP. I mean, I get it, but it chews up a lot of everyone’s time.
In my own field, I’d love to pilot something like this for MS, pharmacoresistant epilepsy, stroke, or other conditions that are common enough to have enough patients to be able to learn something useful. How do we integrate primary and specialty care to improve quality, lower costs, and make it easier for patients?
joel hanes
My daughter has been seeing the same personal physician for 30 years.
But her insurance has often changed, and often been narrow network — so the internist who is in reality her PCP has often been out-of-network. She will not change doctors.
Narrow networks are a demonstration of the utter pathology of for-profit health insurance.
maryQ
We see our daughter’s cardiologist much more often than we see her pediatrician. But I see her pediatrician for hugs and coffee and general advice on parenting a kid with a major health condition. I see my ob-gyn once a year, and couldn’t even tell you who my PCP is right now because it keeps changing.
Consider Phlebitis
It was literally almost 20 years before I met the person who was listed as my PCP. Before that I saw a series of residents. Now I’m old enough to have a couple chronic conditions that merit more continuity in care.
Neil Blumengarten
@Hunter Gathers: Good choices, but Nine is my Doctor. Fantastic!
Johannes
@Emma: Good picks. (Er, you did mean *Tom* Baker, yes?)
Johannes
@Yutsano: Grew up a Davison fan, and came to McCoy later in life. Nothing against Smith, mind you–he’s quite good when on form (and excellent in The Crown)–just Capaldi’s interiority is so impressive–I love how he had to psych himself up into the Epic Speech of Epicness in “Flatline.”