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Sleep Apnea, Snoring, Narcolepsy,
Insomnia and Other Sleep Disorders.

THE SLEEP SITE  

CASE VIGNETTE.


Bill Andrews was a well trained, conscientious internist. He still managed to enjoy his practice for the most part, despite the aggravating barriers to good care imposed by some third party payors with whom he had no choice but to participate. He sincerely liked most of his patients. But for the life of him, he never could understand how his staff managed to schedule his most frustrating patients all on the same day.

Monday, January 11th was one of those days.

"Mrs. Eldon said that you rushed out of the room without writing all of her prescriptions."
"Well, bring me her chart!--I'm running behind."
"Dr. Andrews, she says she needs to talk with you more before she leaves because you didn't even answer all of her questions."
"For God's sake--I answered the first eighty of them! What does she expect?"

Andrews immediately visualized the elderly woman in exam room three. She always seemed to have all the time in the world. Certainly, much more time than he had. Worse yet, she routinely arrived with a plastic bag filled with paper scraps on which she had scribbled questions. She always insisted upon reading each question aloud to him, one at a time--resisting his efforts to scan the questions himself, which would have been quicker. She also claimed that her questions were far too important to discuss with a nurse. He had yet to see why.

"Mrs. Eldon also wanted to know why the phone call you took during her appointment was more important than her problems."

Actually, it had turned out not to be. Andrews had wasted five minutes arguing with a pharmacy over a demand that he fill out some two-page fax form immediately, simply so one of his patients could fill a single prescription that he already had written the week before.

Immediately thereafter, as he was walking back to finish up with Mrs. Eldon, he was waylaid by another of his employees: an insurance clerk who was beside herself. As usual, her problem involved MaxCare One, a new HMO. Unlike the other third party payor organizations with whom Andrews had enjoyed a longstanding, cooperative and mutually beneficial relationship, MaxCare One instead seemed intent on erecting frustrating barriers to the delivery of good care.

Now, Andrews was told, it had failed to preauthorize a medically necessary procedure scheduled to be performed later that same day...despite the fact that authorization had been requested some fifteen days ago.

Andrews was furious. It wasn't the first time that they had dropped the ball. Furthermore, that particular HMO's medical director routinely refused to return his calls. Thus, he next wasted yet more time by berating an HMO representative on the telephone. She attempted to lecture him on what tests were warranted for that patient's illness. She couldn't even pronounce the name of that illness correctly: which increased his anger. For all he knew, she may not have been housebroken--and he felt like telling her so.

Damned MaxCare One. The whole scenario was ridiculous. He resented being told how to practice medicine by MaxCare One clerks whose last jobs may have been in the fast food industry. Because of that HMO, he was having to scramble to see more patients per day. At the same time, his income had dropped and his overhead had increased. He realized that as a gatekeeper, he was having to pay his own employees to perform MaxCare's "scut work".

He scribbled the prescriptions quickly and instructed the MA, "Tell Mrs. Eldon to write me a letter about the rest of her questions." He then looked at the flag by room one.

"What patient is in there now?"
"Ralph Waxman. He came late again."
"He was supposed to be here an hour ago. Why didn't you people just reschedule him?
"We didn't have a choice. He made a scene at the window like last time, but worse."
"So, what did he do that Sarah couldn't handle?"
"Well, he started to yell again. What he said this time made us and the other patients in the waiting room nervous. He said he would be damned if he would take more time off work to come back at another time, because you never helped him anyway, and because he didn't see where he needed medical care to begin with. Then, he said he was going to call MaxCare One because he knew his rights. He threatened to tell them that since you were refusing to give him the care to which he was entitled, he was going to get them to terminate you. He said his brother knows the head of their 'doctor dumping committee', as he termed it."

Andrew' stomach churned. Swell. His practice was in good part dependent upon MaxCare. They had low-balled their rates to the point that most of the major employers in the community had contracted with them. He didn't see how he could survive without them...as hard as it was to live with them. While he despised their high-handed tactics, to be terminated by them would probably prove devastating.

"Cool down,", he told himself. He grabbed Waxman's chart out of the bin on the door and pushed it open after a hasty knock, trying to force a smile that he didn't feel.

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COLUMBUS COMMUNITY HEALTH
REGIONAL SLEEP DISORDERS CENTER
Accredited by the American Academy of Sleep Medicine.

Robert W. Clark, M.D., Medical Director
1430 South High Street
Columbus OH 43207

Tel: [614] 443-7800

Fax: [614] 443-6960

e-mail: flamenco@netexp.net

 © Copyright 2006 Robert W. Clark M.D. Inc.