My frustrations with working in an outpatient setting revolve around two core issues: continuity of care and insurance. I don’t want you to walk away from this post without hope or think that outpatient healthcare is a catastrophic disaster. However, I do think it’s helpful to consider the problems that I see on a daily basis and brainstorm ways to improve aspects of preventative medicine, since it directly affects the flow of inpatient hospital settings and global health on a wide scale.
Continuity of Care
It is incredibly hard to keep care continuous in outpatient offices. Let’s start by imagining a family practice office. In a sense, it’s a catch-all office.
When a health situation arises that the family doctor cannot address, she or he refers the patient to a specialty clinic. Let’s follow a hypothetical example: Lauren, a 29-year-old woman, comes in to the family practice office for her annual exam. Lauren’s blood tests show her iron levels are low and leaves with a referral to an OB/GYN. She also leaves with a referral to an eye doctor because it’s harder to read road signs lately, and a referral to a dermatologist for a mole that looks suspicious in color, size, and shape.
Lauren has to call all of the specialty offices to make appointments. The family practice office must fax her records to each office, before every scheduled appointment. After the appointments, the specialty clinics must then fax or send all the reports back to the family practice doctor, who must then coordinate everything to best direct the patient’s care.
It’s no wonder information gets missed or delayed with so many moving pieces. When a specialty office is presented with a patient that has multiple health problems, the specialty only focuses on one aspect of the patient. The responsibility of looking at all the patient’s health components is shrugged off from provider to provider.
What if, while Lauren is in the midst of coordinating multiple appointments with different specialty clinics, her iron level gets too low and she has a fainting episode that takes her to the emergency room? Her visit to the ER involves pregnancy tests, blood tests, and frantic assessment as healthcare workers grapple with trying to figure out who she is and what her health history is. It is rare for hospital systems to be networked to outpatient systems, so it’s time consuming trying to communicate between the two settings. And this is why continuity of care is so darn difficult: because there is no easy way to communicate between acute to outpatient settings nor from primary care to specialty care. The responsibility lies heavily on the patient to coordinate their own care, which they often don’t know how to do.
Insurance is another huge frustration in the realm of outpatient healthcare. I don’t know if there’s a set of words that spark more anxiety. I sat through hours of nursing lectures in school and I think a total of four hours were devoted to explaining the difference between Medicare and Medicaid.
What I’ve experienced in the past few months of nursing is much more complicated than that. Health insurance, what some people argue is a necessary evil, is a multifaceted maze of discombobulation that makes my head reel, As a healthcare worker, I feel like I should know more than I do about navigating the intricacies of insurance. I’ve run into a lot of scenarios with insurance that just plain don’t make sense to me. I bet I’m revealing my naivety right now, but sometimes it takes a fresh look at a problem to cause others to change their ingrained perspective.
Preventative doctor’s visits are covered by insurance. Some office visits are not covered. Insurance fails to cover a visit when patients need a doctor. A mom is often forced to decide whether she should wait her child’s illness out or pay $200 to see a doctor for medication. When I work to triage phone calls at the pediatrician’s office, patients or parents are often weighing the risks vs benefits of coming in.
A second frustration with insurance is related to medication coverage. When a patient needs a medication at an office visit, the doctor will write a prescription and send it to the patient’s pharmacy. It seems like a fine system.
For example, a pregnant woman in her first trimester comes in to the office with nausea, so the obstetrician prescribes Diclegis. Or picture a doctor sending in a Ventolin inhaler for a child with asthma exacerbations. More often than not it seems, my office receives notices from pharmacies requesting a prior authorization or alternative medication to the original medication because insurance won’t cover it.
The prior authorization process is a beast, involving an appeal process that requires the prescriber’s office to verify the patient truly needs the medication. In a sense, you have to argue on the patient’s behalf so they can get the medication. If the pharmacy sends an alternative prescription request, it is because insurance only covers a certain form of the medication. All the back and forth between a pharmacy and the doctor’s office gets tedious for clinical staff and ultimately causes delays.
Bringing it Back
Regardless of the frustrations that I feel with outpatient healthcare, I don’t want to downplay the power I believe that preventative medicine can have in patients’ lives.
Taking good care of yourself before an acute illness happens can benefit quality of life on an individual level, and positively benefit society. However, there are a lot of improvements to outpatient medicine that can and should happen. I hope that more people can use the faults in our system as propellers to move toward change.
What do you think? Do you share these frustrations? I would love to hear other nurses’ perspectives.