The era of the super-specialist | About
using your health insurance plan as a guide | The
business of being a super-specialist | How
to find a super-specialist | Cues
on physician competence | Using
the Internet for information | Get
a second opinion | Be willing
to travel | The physician
visit | Be a good patient
There are tremendous advances taking place in medicine
today, but in order to benefit from them, the healthcare consumer must
take an active role. The best healthcare will not find you; you have
to seek it out.
While the United States offers the highest standard of
healthcare in the world, there is still huge treatment variation based
on the doctor you see. Bottom line, the doctor you choose will determine
the quality of care you will receive. Here is an overview of how to
navigate through the healthcare system to find the best doctor for
you.
The era of the super-specialist
First, the healthcare consumer needs to understand that today’s
medical field is divided into very narrow specialty categories. Years
ago, the general practitioner addressed a variety of problems including
heart, lung, orthopedic, and neurological problems. With advancing
medical knowledge has come specialization and sub-specialization. Now
these same problems may be treated by a cardiologist, pulmonologist,
physiatrist, and neurologist. While an orthopedic surgeon in
a small rural town may still address a myriad of orthopedic problems,
in a larger setting sub-specialized orthopedic surgeons may limit their
practice to the upper limb, or knee, for example. Therefore, the educated
healthcare consumer with a knee problem should seek out an orthopedic
surgeon who only works on knees. This increases the likelihood that
the surgeon will be more proficient in surgery and will use the most
advanced surgical techniques available for knees.
Spine specialists can include neurosurgeons specialized
in spine surgery, orthopedic surgeons specialized in spine surgery,
physical medicine doctors, anesthesiologists and physical therapists
who specialize in the nonsurgical relief of back and neck pain symptoms.
As with anything in life, practice makes perfect. All
clinical outcome studies confirm that the more times a surgeon performs
a procedure, the better they become at it. Consequently, spine surgeons
who perform more than 150 surgeries per year will be more proficient
than those who perform 50 each year.
A second indicator of quality is training and experience
of the physician. One might believe that a younger physician a few
years out of training might be at a disadvantage compared to a surgeon
who has practiced for 25 years or more. However, this is not an accurate
generalization. In reality, an older physician may be more comfortable
using traditional techniques, while a younger, fellowship-trained physician
may be trained in the most modern, minimally invasive techniques and
instrumentation. Age is not necessarily a good indicator of quality.
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About using your health
insurance plan as a guide
Most people are surprised to learn that their health
insurance provides little help in finding the best specialist within
a specific niche. Offering a preferred provider directory of specialists
gives no real indicator of quality. Inclusion in a PPO directory typically
only means that the physician has agreed to accept a discounted rate
for payment from the insurance company. In this sense, “preferred
provider” simply means that the insurance company would “prefer” you
to see doctors who have agreed to accept a discount. These discounts
can be steep, depending upon the health insurance plan.
Unlike other industries, in which market demand and the
highest quality product commands the highest price, healthcare is an
industry that is woefully behind the times. But that is changing.
A growing trend nationwide is that super-specialists,
who are in the highest demand by virtue of reputation and outcomes,
can be less motivated to accept discounted reimbursement from some
health plans. These super-specialists typically have full schedules
and don’t need to discount their services to attract patients.
Consequently, they are opting not to be included in a PPO panel, while
other physicians may have to rely on discounting to attract patients.
Most PPO plans have out-of-network benefits
that enable patients to see a physician who is not listed in the PPO
directory. Typically, the person may have to pay a larger percent of
the bill and a larger deductible. But for complex problems, this still
may be the more prudent approach in the long run to access the most
current technology and the specialist with the least invasive treatment
alternatives.
More and more employers are recognizing that traditional
healthcare plans have historically done a poor job of establishing
panels of physicians based on quality care. Consequently, several employers
are seeking out centers of excellence for the treatment of complex
problems like cancer, heart disease, neuroscience, organ transplants,
joint implants and spine problems.
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The business of
being a super-specialist
Part of the problem related to PPO panel discounting is that it penalizes
top super-specialists who invest in the most advanced and expensive
technology for their offices, highly trained physician assistants and
a modern clinic facility with multiple capabilities under one roof
for patient convenience. By being on a PPO panel, a super-specialist
who has invested additional years in training, fellowships and advanced,
continuing education courses in the latest procedures must accept the
same level of payment as a generalist who has not similarly invested
in training, support staff and clinic facilities.
In this sense, health insurance plans are not able to
steer consumers to the highest quality physicians. They are, however,
in a difficult position because they find themselves somewhat handcuffed
and unable to direct consumers to the highest quality physicians. On
one hand, every healthcare plan medical director knows that the best
physicians and super-specialists will save money as their outcomes
improve and as they provide minimally invasive surgery options that
are less risky. These directors are trying to determine ways to subtly
encourage patients to seek out centers of excellence for complex problems.
However, they are also concerned with possible litigation from other
physicians that may develop if they overtly favor one center over other
physicians.
Under this current scenario, healthcare consumers are
left on their own to search for a top healthcare provider. It is their
responsibility to research the best center of excellence for treatment
of a complex health problem.
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How to find a super-specialist
There are many ways to identify the best specialist within a given
area. A good place to start is to consult a family practice doctor
who addresses your general healthcare needs. This “primary
care” doctor will usually know the best super-specialists within
a specific region. Also, since this primary care physician may have
referred patients to that specialist before, they may have seen firsthand
their clinical outcomes after surgery. If these outcomes are poor,
the primary doctor will not refer additional patients. |
On the downside, this referral process abdicates the
selection process to someone else. The educated healthcare consumer
would do well to perform secondary research to identify the best possible
specialists and clinics within a given specialty.
The Internet can provide a wealth of helpful information.
The educated consumer can locate information on a doctor’s education,
training, clinic and area of specialization.
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Cues on physician
competence
Fellowship training, the highest level of training in the United States,
can be an indicator that the physician has invested an additional year
in a specific area of specialization. Note where the physician has
trained. Training at a large or prestigious institution would expose
the physician to more complex cases, which in turn makes them more
proficient in their chosen specialty.
Board certification is another criteria that indicates
a physician has met the competency standards within an area of specialization,
as judged by the specialty board. Board certification typically requires
that a physician has been in practice for several years since graduating
from medical school and has passed a rigorous written and oral exam.
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Using the Internet
for information
When looking at a physician’s own Internet site, determine if
the physician takes a multidisciplinary approach to his specialty.
Typically, the best specialists will place a variety of complementary
services under one roof for the convenience of the patient. This center
of excellence approach can involve having therapists who are specialized
in a particular niche as well as an internal diagnostic center with
X-ray, MRI and treatment suites, so that patients don’t need
to drive around town for various diagnostic studies or treatments.
Complement this search within individual Internet sites
with a review of reputable national sites that provide overall information
about a specialty. These sites will list all the various treatment
options for a given problem, including watchful waiting. Then compare
this impartial, unbiased list with the recommendations provided by
a specific clinic’s Internet site.
Beware of sites that appear to be informational but are,
in fact, steerage devices for physicians who pay the site to be listed
as “preferred providers.” Typically, the only impartial
sites are those related to the specialty boards of the American Medical
Association such as the American Academy of Orthopedic Surgeons (AAOS)
or the American Academy of Neurological Surgeons (AANS). The societies
responsible for board certification usually provide a nonbiased listing
of the board-certified physicians in your area.
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Get a second
opinion
Most health insurance plans advise or require that the healthcare consumer
receive a second opinion when treatment involves a complex surgical
procedure. This is excellent advice. Furthermore, the healthcare consumer
should not inform the second provider that their visit relates to a
second opinion, since some physicians are reluctant to provide conflicting
opinions. If you have received two identical, unbiased opinions related
to your diagnosis and recommended treatment, you can proceed accordingly
with more confidence that you are pursuing the right approach.
If the two opinions disagree, you should examine the
training and qualifications behind each opinion to determine which
is most likely the correct recommendation. Another option is to pursue
a third opinion, but this can add to your confusion.
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Be willing to
travel
The trend in medicine is that the best specialists are creating Centers
of Excellence that focus on certain problems like cancer, neuroscience,
spine problems, diabetes, asthma, etc. Because the cost of developing
these centers is high, they typically exist only in larger cities.
Consequently, if you need complex surgery, be prepared to travel.
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The physician
visit
The best specialists within a given niche will typically provide all
the appropriate nonsurgical and surgical treatment options for your
problem, along with the pros and cons of each approach. In some cases,
treatment may include watchful waiting. If your doctor is unwilling
to answer questions about your diagnosis or treatment, you’re
in the wrong place. Go find another doctor.
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Be a good patient
After all the searching, if you’ve found a good doctor, the rest
is in your hands. To be a good patient, you must comply with the physician’s
recommendations and prescriptions. Too many times, it’s natural
to want a magic pill or miracle surgery to provide an easy route back
to activity. However, you should always view surgery as the last card
to be played, after all nonsurgical options are explored.
For nonsurgical treatment alternatives to work, the patient
must often follow physician and therapist prescriptions, which may
include a commitment to therapy. For spine and joint problems, this
may mean incorporating special strengthening exercises that rebuild
supporting muscles, so that surgery isn’t necessary. While athletes
are familiar with the required commitment and pain associated with
the exercise gym, others may not be. It can be new territory for many
people, but it is essential if you are to give nonsurgical options
a chance to work.
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