Type 1 Snobbery and Regional Differences

I moved to South Coast Massachusetts from NJ because of the bio-pharma work opportunities in Cambridge and the Greater Boston Area.

As part of the process, I have begun transitioning my medical support team. In NJ I had no Primary Care Physician, but did have a bunch of doctor’s I visited 4 times a year (endocrinologist, diabetic podiatrist, retina specialist) I also had a number of MD’s I visited on a different schedule (pulmonology, dermatologist, etc.). My insurance did not require a referral.

In Massachusetts, I am on Medicare plus a supplemental policy that allegedly lets me go to any doctor without a referral. However, every endocrinologist that I called said that I needed a referral from a PCP!

So I made an appointment to explore my options. The PCP I visited said that I would need to get a referral from her every time I wanted to see an endo.

Now I have been a Type 1 44+ years and have had an A1c <7 for 2 full years. I always had a direct relationship with my endo (I also have Hashimoto’s Thyroid). When I asked the PCP why this arrangement since my insurance does not require it, she asked me who was going to “manage” my health? My answer was the same person as before - me!

Here’s the snobbery thing. This PCP was trained in India and did a residency at at an average/mediocre U.S. Hospital. In our conversation she mentioned that she thought an A1c of 6.4 was too high and I should be in the 5’s! Never mind that she did not wash her hands before examining me.

Help! Is this really how medicine works in SE New England?

Hmm, I would be skeptical of the doc that’s telling you that. Maybe she doesn’t understand HMO vs. PPO or something like that, or perhaps her practice has decided to go HMO regardless, because that’s how they roll? It sounds very unusual but I don’t know that much about Massachusets. It seems like you are loaded for bear on coverage so without a more detailed explanation, I would do an end run around her and find my own endo. That’s pretty much what I’ve always done and it usually works pretty well, although sometimes, I have been less than “completely satisfied” with doctors too.

No, think it’s more medicare/other policy that is forcing you into the situation. Many moons ago I chose my Endo as my PCP, knocks one of that list of docs we have to visit regularly. I would look for a different PCP as she will have you in a coma with that A1c target…

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I believe what you are finding in Massachusetts, is a form of insurance billing I have heard called “referral churn”. Specialists don’t take customers off the street; they only accept referrals from PCP’s, and the PCP requires a billed appointment to give each referral.

It’s not necessarily insurance fraud. This waste is in fact often required by insurance/medicare policies in their effort to reduce costly specialist visits. I think it’s a kind of an industrial action, “work to rule”, against the insurance/medicare structure.

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I would call the supplemental insurance and ask for a referral there. I would also give them your PCP experience…namely the hand washing detail. I don’t know who your insurance is but in my own I can speak with them and get some health advice and recommendations and such. I found an excellent PCP when I moved by asking my insurance for recommendations in my area and in their network. I hope you can find a better health provider, at least one that will wash her hands before checking you out.

She’s a bit confused.

If you have an HMO, you need referrals; if PPO you can (with some limitations) go to any doc who takes Medicare.

I cannot use the PPO approach if I cannot find a doctor that will accept an appointment.

I probably wasn’t clear in my first posting. The three local multi-specialty medical groups seem to have gobbled up all the most of the local M.D.'s. All three have adopted the policy I described - PCP first and always. My supplemental insurance is also PPO. While I pay an extra premium for the policy, the collusion among the three large groups effectively makes everyone play the HMO game.

In NJ my endo was in a small concierge practice. They accepted Medicare, all other paid cash and had to get reimbursement from their insurers. I knew the landscape in NJ. Here it looks like these policies were put in place based on Romney’s program before OCare. I am hoping that someone is aware of M.D.'s that aren’t ensnared.

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Karen,
That makes sense, I was just working off their network list on line, but I should go live. Payers have no motive to break up these policies becuse it costs them less but they may be more responsive to the informed patients.

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Thank you, I am looking for experienced citizens who may have already solved this. I was REALLY surprised because this looks and smells like Britain’s NHS. What’s worse is that the people I speak with do not realize that other parts of the country have a different approach.

Wow! That sure sounds messed up, huh? A PPO plan and the docs want referrals. I have an Aetna PPO which lets me go nearly everywhere–I say nearly because yesterday I called a doctors office and they said they don’t get enough reimbursement so I’d have to pay extra if I wanted to use that doc. Yet they are “in network” for Blue Shield. go figure.

I agree with Tim. My job’s insurance is PPO; however, it requires for you to see any specialist you must get a referral from your PCP–a rubber stamp of approval that the PCP can’t “do the service” and must refer you to someone more specialized. It’s a money racket.

My mom has the same insurance as secondary (retired) and Medicare as primary; however, she was “grandfathered” at her retirement before referrals were even created. She doesn’t need a referral to see any specialist. Yet every so often she runs up on a snotty nosed, greenhorned office staffer who demands a referral and we have to go around the rose bush with her. Then Mom will tell her to call the insurance company. I guess the staffer gets a representative who tells her to ‘shove the referral where the sun don’t shine’ because it never fails that generic Lil Ms. Know-It-All comes back all red-faced and apologetic.

When I retire (if I ever get to retire), I’ll have to fight the referral racket. I hate it with a passion! And doctors do refuse to take you without the referral OR you pay full price (out of network) upfront. It’s a racket.

Outrage is the most civil word I can use to describe it, Our community here at TD is basically made up of professional patients. We have to be. Thinking of all the “normal” people and the sub par medical care some of them must deal with really is an outrage.

One thing to consider re referral requirements at some specialists’ offices: it’s not always about any insurance requirement but the fact they don’t want to waste their time with patients that don’t have a pressing need for their specialty–such as a surgeon who has no desire to see patients who don’t need surgery. Docs don’t want to fill their schedules with patients they’d never see again. ie they want referrals from another doctor who already has determined a more certain need for one to see a particular specialist. I’ve had this happen a few times, myself.

Personally, my PCP did refer me to an endo. It’s was 7 months wait for a self referral. New endo called on a Sunday at 8 pm asking me if I could be in his office on Monday at 9 am. I was sort of impressed, but I wondered how sick I really am.

Somewhere along the line, I got pissed at the PCP for not taking me seriously or acting like I’m dumb or something. I compained to him at 3 visits about being tired all the time, and sometimes dizzy in my head. He sent to get a MRI and supposively that was normal. Never know what’s really in the report because I supposed he thinks I"m too dumb to read it. When I had the “silent heart attack” which was’t all that silent since I had been complaining with fatique for months, I decided I have no use for him. He cancelled his appt with him, and I decided I didn’t need him any more. What do u need a PCP for after the referral. I think it’s all a racket for him to keep billing insurance for no reason.

That was my thinking, too. There is a shortage of endos in Massachusetts where it has been illegal for health insurers to refuse coverage to people with chronic conditions for at least the past 20 years. Because people who need treatment can get it, independent of their employment status or income, even the most incompetent endos are booked solid.

So the idea of the referral is to avoid wasting their time with people who have nothing wrong with them but are convinced they need to see endos.

I didn’t realize what a big problem this is be until I started running my web site and getting mail from around the world. A significant number of the people who contact me have perfectly normal blood sugars, but are still convinced they have diabetes. These are the people who write that they tested their blood sugar after eating and it had surged to 115 mg/dl from 82 and their A1c is 5.2 but they just know that high blood sugar must be the reason they have pains in their elbows. They often write that they are upset that their doctors won’t give them a referral to an endo.

So with that in mind, perhaps you can understand the reason for that limitation.

The fact that self-employed people in Massachusetts with preexisting conditions have been able to get insurance for the past 20 years makes it worth putting up with the occasional conveniences. In other states I would never have been able to get insurance at all.

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That makes sense. Years ago, my PCP’s medical group required a doctor’s appointment just for a referral ($20) plus $5 for processing of the referral. I think they got in trouble for charging. Now you make the request electronically with no charge to the patient. My insurance is BCBS that has now changed to United Healthcare. I left my job for a short amount of time for another job, and the new job carried Cigna insurance and didn’t need a referral, it was a dream to be able to call a doctor and make an appointment without having to go back to my PCP. I hated the job, but loved the insurance coverage. Now I’m back to my old employer and same ole insurance process.

The first thing out of an office staffer’s mouth when you call to make an appointment is not what your condition is but what insurance you have and whether it is HMO or PPO. Sometimes they will take down your information and contact your insurance company to see if your are really “in good standing” and then call you back to make the appointment. In the Houston area, most doctors I’ve dealt with say not to call their office for an appointment until they received an approved referral from your PCP.

Now one big problem is if you get have a crappy PCP who thinks he or she can take care of your condition and refuses to refer to a specialist–I’ve had friends and co-workers who have fell into those situations. By the time the doctor decides to send the person to the specialist, they may be headed to the hospital or the specialist has lost a lot of ground on getting a handle on the condition.

My biggest issue with doctor referrals isn’t the insurance aspect, but the fact that my Primary Care doc is in a group that requires referrals be made to specialists in the group. I haven’t been too enamored of any of the specialists in that group!

yeah I felt the PCP was mad at me for having an heart attack and taking the cardiologist on call. Hey it was an emergency, didn’t have time to decide who will save my life.

The PCP is mad at me for letting the cardiologist prescribe no statins for me. It’s wasn’t me that prescribed no statins, the cardiologist thought they were damaging me. So the PCP chastised me and told me i’d be back where I was without them. Whoa I had a heart attack, those statins didn’t save me. Anyway, I got the impression that I didn’t use their cardiologist that they had no use for me.

I am very glad you survived the experience. If you guys could give some indication of the State or region where you live maybe we can uncover a pattern.

Most group physicians are on a schedule of 10, 15 or 20 minutes per patient seeing 3, 4, or 6 patients per hour. My NJ doc’s uniformly tell me that EHR take time away from the patient and make it harder to connect the symptom “dots” when do these folks get time to stay current in the literature or, more horrifying, are they getting the information from Pharma sales reps?

I’m from Louisiana and see my docs in Baton Rouge, so have many to choose from.