Following last week’s post, here’s the story of Shannon*…a patient who has suffered one of the horrible manifestations of diabetes, blindness. She uses the assistance of a wonderful guide dog whom we love to see each time they enter the office together.

This story is an example of how you cannot expect recommended guidelines for preventive services to be 100% true all the time.  Here’s a little background. It  is recommended that Diabetic patients need to have annual eye exams to screen them for diabetic retinopathy and other ophthalmologic manifestations of diabetes that can lead to blindness.  Medicare and insurance companies thus judge a primary care doctor’s quality care of diabetic patients in part by making sure that the patient has had their eye exam annually.  This is proven to the insurance company by the eye care provider submitting a certain CPT code (Procedure code) on a claim and sending that claim to the insurance company.   However, for diabetic patients that have already experienced these complications and are already blind, they are still labeled as having a “gap in care” and thus non-compliant.  Of course there is no real penalty for the patient except that they will get phone call after phone call telling them to go get an eye exam. But, their primary care provider is actually penalized for this.  I’m telling you this from experience with this exact scenario within my own practice with patients being labeled as “non-compliant” for services that were not necessarily indicated.  I’ve had to tell my own patients that they need to go see a specialist that they don’t really need to see, pay a copay they don’t really need to pay, spend half a day in a specialists office they don’t really need to spend,  and have an exam they don’t really need in the name of “improving quality of care, reducing costs and improving patient satisfaction.” 

Shannon stopped having the recommended eye exams several years ago after she lost her sight and there was no longer any treatment available to help her.  But, her insurance company doesn’t really care about that because they are required to report the compliance of their Diabetic patients with their annual eye exams.  They were contacting us and Shannon repeatedly to encourage her to get her annual eye exam to screen her for the complications of Diabetes that could lead to blindness…which she already has.  It is not preventive care anymore when you are screening someone for something you already know they have!  Despite my efforts to talk at length to the insurance company to explain this, they still mandated it.  So Shannon and her guide dog spent half a day and a wasted copay getting her eye exam so that she could be told she was blind and there was nothing they could do.

So here’s the thing about the value based payment model of healthcare that is being paid for in large part by third parties (insurance companies and Medicare), not patients; patients are loosing their choice of what medical services they want or don’t want and yet are being expected to become more engaged in their own healthcare at the same time.   I can understand these third parties having to come up with some way to force improved preventive services being ordered and followed through for our country’s population, particularly given our healthcare costs are sky rocketing even while overall health is declining. From a population health management perspective, the guidelines that are published by the US Preventive Services Task Force are rigorously studied by Population Health Experts and they are guidelines for a reason – they help large groups of patients be healthier as a whole for reduced costs as a whole.  What I fear is being overlooked is that the implementation of this “improved quality of care” is most dependent on quality doctor-patient relationships where it is decided together what services each individual patient needs.  In Shannon’s case, this requirement did not improve quality of care, it increased costs both to the patient and the healthcare system and certainly did not improve patient satisfaction – the exact opposite of the intent.

This post is not about patients not needing to follow the important preventive services that their doctor recommends.  It is about showing the practical implications for you as an individual patient under our healthcare system. I think it is helpful for individual patients to realize that when a third party is paying for your healthcare with limited funds in a value-based payment model, “individualized medicine” is hard to practice (even though everyday more genetic advances are made that make individualized medicine an inevitable way of the future).  I find it ironic that part of becoming a “Patient Centered” healthcare system means finding ways to force patients into having preventive services they may not want and limiting choices of what types of diagnostic testing and treatment options are available all while asking patients to become more and more engaged with their own healthcare.  I feel that as I have been seeking to improve how “good” of a doctor I am in Medicare and Private Insurers minds, I’ve become more of a paternalistic provider than I ever have been. ​

*Shannon’s name has been changed to protect her privacy and her story has been used with her permission.