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Thu Jan 20, 2022, 10:59 AM

I know there are medical professionals on the DU. I have an issue with gatekeeper medical care.

I would appreciate it if you give me your thoughts -- good and/or bad -- on this system. I find it very frustrating when the need for a specialist is obvious that one has to wait not only for a primary care appointment, but then get in line to see the specialist.

Also: Is anyone else frustrated by this system?

Thanks in advance for your comments!

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Reply I know there are medical professionals on the DU. I have an issue with gatekeeper medical care. (Original post)
Scottie Mom Jan 2022 OP
Hugh_Lebowski Jan 2022 #1
Scottie Mom Jan 2022 #2
Klaralven Jan 2022 #7
Scottie Mom Jan 2022 #10
lagomorph777 Jan 2022 #3
MineralMan Jan 2022 #4
Mosby Jan 2022 #8
MineralMan Jan 2022 #18
Scottie Mom Jan 2022 #11
Sgent Jan 2022 #14
Scottie Mom Jan 2022 #20
MineralMan Jan 2022 #17
haele Jan 2022 #5
Scottie Mom Jan 2022 #12
multigraincracker Jan 2022 #6
Scottie Mom Jan 2022 #9
highplainsdem Jan 2022 #13
Scottie Mom Jan 2022 #15
Aristus Jan 2022 #16
Scottie Mom Jan 2022 #19
Hortensis Jan 2022 #21

Response to Scottie Mom (Original post)

Thu Jan 20, 2022, 11:05 AM

1. Yes it annoys, and don't even get me started on the system surrounding getting sleep apnea equipment

That you obviously need ... it's pretty much a nightmare.

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Response to Hugh_Lebowski (Reply #1)

Thu Jan 20, 2022, 11:19 AM

2. It took me SIX MONTHS to get to a specialist for an obvious medical problem...

...which had been diagnosed years before and before gatekeeper medicine.

I made a complaint to the California Department of Insurance and because I have Medicare, they made a complaint to Medicare.

Was their system corrected by the insurance company? No. They sent me a nasty letter in essence saying how dare I complain to Medicare. I sent them the letter from the Cal DOI and told them to talk to them and not me.

What gives with this BS????

Sorry you had this kind of trouble. Years ago, I could just call a specialist, state the problem and get an appointment...not so anymore.

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Response to Scottie Mom (Reply #2)

Thu Jan 20, 2022, 11:51 AM

7. Do you have a Medicare Advantage plan, i.e. Medicare part C?

 

AFAIK, no referrals are needed with original Medicare Parts A & B?

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Response to Klaralven (Reply #7)

Thu Jan 20, 2022, 12:10 PM

10. Just have A and B...

...but still get the run around.

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Response to Scottie Mom (Original post)

Thu Jan 20, 2022, 11:21 AM

3. It doesn't even make fiscal sense.

They have to pay two docs instead of one.

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Response to Scottie Mom (Original post)

Thu Jan 20, 2022, 11:23 AM

4. I'm not a medical professional, but this is driven primarily by

health insurance company policy. Since specialists bill at higher rates than primary care doctors, they want people to go to the primary care MD first. That's because, in most cases, the primary care doc can treat immediately and the specialist might not be needed. If needed, the referral gets made. Of course appointments with specialists are often hard to come by in a timely way.

Different insurance companies have different policies, though. And it takes different amounts of time to be seen, even by primary care doctors, depending on where you live. In the Twin Cities and with my insurance's health care system providers, I can be seen the same day or the next day by a primary care doctor - usually my regular one. My network includes one of the largest clinical networks in the area. Specialist appointments within that system can take a couple of weeks to a couple of months. That depends partly on how serious the issue is, of course.

There's no one answer to your question. It depends on many factors. However, in most systems, you're going to have to be seen first by a primary care doctor before you get referred to a specialist. In truth, most specialists won't make appointments for self-referred patients. They also want an evaluation by a primary care physician as part of their triage protocols. Otherwise, they see too many patients who don't need their services and who could be treated at the primary care level.

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Response to MineralMan (Reply #4)

Thu Jan 20, 2022, 11:56 AM

8. Like you said, it's a function of your insurance more than anything.

I self refer any time I want, but the issue is how long it takes to see the specialist.

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Response to Mosby (Reply #8)

Thu Jan 20, 2022, 12:41 PM

18. Every insurance company handles things its own way.

Often, too, specialists may not see you without a referral. It just all depends.

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Response to MineralMan (Reply #4)

Thu Jan 20, 2022, 12:15 PM

11. So they pay for a primary to refer to a specialist?

That seems to cost them two MD visits and not one.

There is nothing that a primary can do for the condition I have. I was diagnosed at UCLA in about 2000 with a hereditary disease of my hands. So now a primary MD with no ortho specialty has to say that 22 years ago a UCLA hand specialist that teaches at the medical school was right before I can see a hand specialist?

This is crazy!

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Response to Scottie Mom (Reply #11)

Thu Jan 20, 2022, 12:21 PM

14. If you already have a primary doctor

just call and ask for the referral? They don't want to see you either just to refer you to surgery if its already been diagnosed.

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Response to Sgent (Reply #14)

Thu Jan 20, 2022, 01:11 PM

20. The DO primary care MD I had retired and I was assigned a new PC doctor.

The runaround immediately started. If someone would look at the records...that might be a good start.

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Response to Scottie Mom (Reply #11)

Thu Jan 20, 2022, 12:39 PM

17. Well, I'm not talking about your particular situation.

Your 22-year-old diagnosis probably doesn't register with your current insurance company. So, they want your primary MD to refer you, I'm sure. Do you have records from that previous UCLA doctor?

Since I don't know anything about how your health insurance works, I can't really say much about it. You might want to call the help line for your insurance and explain your situations. Maybe you already have. But, odds are that you'll need to see your primary physician, who will listen to you about your diagnosis, and probably do the referral without much ado.

What I described is why they do that system for people as a general rule. Your case is your case. But, in most cases, they want you to see a primary care physician to see what that doctor says. You might be able to bypass that, but I doubt it. Fees paid to primary care docs are lower than specialist billings, which is why they do it. With new diagnoses, the primary care doctor can often initiate a care strategy. Then, the referral comes if that doesn't handle it in typical situations. In your case, the primary care person will probably just make the referral, since you have that diagnosis already. The insurance company might try to get the records from the UCLA doctor, though, just to verify.

Although it sounds irrational to you, that's probably how it will get handled. All medical insurance systems have set policies for such things.

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Response to Scottie Mom (Original post)

Thu Jan 20, 2022, 11:24 AM

5. In my opinion it's corporate sponsored eugenics.

The whole corporate "free market" structure does not value human life over profits. If you aren't wealthy to begin with, it's best that if you (or your family members) have a chronic or fatal health issue that can make you a fiscal risk leave the gene pool as quickly as possible. Doesn't matter if survivability and functionality of someone with a health issue has future ramifications in terms of society in general, the fact that it costs money to mitigate or fix the issue outweighs how talented or positive for the community that person might be.
Get rid of the sick and weak. Doesn't matter if one of them could possibly cure cancer or come up with clean renewable energy, or be the parent/inspiration for the next great artist, scientist, teacher, or doctor...they are a drain on profits. So get rid of them.
After all, people are fungible. Egotistical rich people are precious snowflakes.
Gatekeepers are part of the system to reduce costs to the corporations. Pretend to care, slow down the assistance, maybe the costly weak link will just give up and die off.

On edit - it is cynical of me to rant like this, but over the past ten years or so, I've experienced an increase in "gatekeeper" incidents where an insurance co. Health Care "Advisor" who never met or talked to us or our doctors before deciding a particular medication or procedure was not necessary, and we had to spend months and out of pocket money just to get the insurance to pay for something that is critical for a modicum of functionality.
Almost like they want us to up and die, once the cost to cover our health needs went beyond the premiums, co-pays, and "co-insurance we and our employers can provide them.

Haele

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Response to haele (Reply #5)

Thu Jan 20, 2022, 12:17 PM

12. Boy, do I hear you!

Like I said, Cal Dept of Ins referred my former ins carrier to Medicare for the BS runaround I got.

Yep...it's MONEY and not people that count!

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Response to Scottie Mom (Original post)

Thu Jan 20, 2022, 11:26 AM

6. That's why I like a DO for a primary doc.

More likely to roll up their sleeves and do it. Been my experience.

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Response to multigraincracker (Reply #6)

Thu Jan 20, 2022, 12:09 PM

9. I agree on DOs.

Also, I find medical doctors who will RX Acupuncture are better for me.

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Response to Scottie Mom (Original post)

Thu Jan 20, 2022, 12:19 PM

13. I can see why gatekeeper medical care is frustrating. But without it, specialists would likely

be spending a lot of appointment time on people who could be helped by GPs, and/or their staff would have to find some way to do comprehensive screenings to weed those people out.

And having a patient get a referral from their GP also enlists that GP's experience with the patient's medical history, which might suggest another type of specialist is necessary, not the one the patient thinks they should see.

But yes, the waiting is frustrating. We really need more doctors of all types. The federal government should subsidize the educations of doctors and nurses.

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Response to highplainsdem (Reply #13)

Thu Jan 20, 2022, 12:23 PM

15. I have seen screening forms in use for the specialities

With some conditions, the need for/use of of a specialist is obvious. I think this may be the way to go for screening. A PA, I would think, could see when there is an existing condition that need not be first seen by the PC doctor.

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Response to Scottie Mom (Original post)

Thu Jan 20, 2022, 12:27 PM

16. I can appreciate the frustration this can cause.

As far as being a gatekeeper, I can't count how many patients come in to my clinic with something completely innocuous and not needing any treatment because they consulted Dr. Google. Visits like these aren't really a problem for me at the primary care level. But a specialty care provider can't afford to waste his or her time with a nothing visit like the one I just described. So a visit with, and a referral from, a primary care provider first is not necessarily out of line.

By the same token, I have patients come in to the clinic wanting a referral for specialty care for a condition that I'm able to treat right there in clinic, without any further evaluation. This is efficiency in medicine, and can prevent a hike in medical care costs.

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Response to Aristus (Reply #16)

Thu Jan 20, 2022, 01:09 PM

19. I can understand that your reply, but not all conditions fit the PC doctor first system.

The condition I have is obvious with one look at my hands to most PC doctors. It's a dominate hereditary disease that causes the fingers to contract and needs treatment from a hand specialist. I'm sure you know what this is. However, I cannot tell you how many times I have had to tell a PC doctor what it is. Insurance companies reassign PC doctors for various reasons. Each dang time, I have to start all over again...even when I send the new PC doctor copies of records stating the condition.

It was so simple years ago before no gatekeeper system: I called UCLA hand surgery department in about 2000, told them of the family history and described my hand. An appointment immediately. My maternal grandfather had the condition and I knew what it was when it started.

I am so frustrated with the system I want to scream. I am again starting all over with a new PC doctor who wants to see me to refer to a specialist.

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Response to Aristus (Reply #16)

Thu Jan 20, 2022, 01:41 PM

21. Thanks for an informed response of the type requested. nt

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