I love our health insurance system. In order to visit a specialist, I must first get a referral from my Primary Care Physician. Many insured Americans will be familiar with this song and dance.
It’s clearly meant to model traditional doctor-patient interactions. If my doctor diagnosed a heart problem he felt unqualified to treat, he’d refer me to a cardiologist. If he diagnosed a digestive problem, he’d choose instead a good gastroenterologist. He treats general illnesses, and recommends specialists to treat specialized illnesses.
In this case, I’ve diagnosed my problem without his assistance: I have poor eyesight. I know I should be careful performing self diagnoses even in the Internet era, but I’m confident about this one. You can check my work. First, I removed my glasses and then counted how many events made me say “ouch!” in the following two minute period. I then replaced my glasses and repeated the test. (Let’s just say it was a smaller number and leave it at that.)
Now, I know I need to see an ophthalmologist. You know I need to see an ophthalmologist. My doctor would know I need to see an ophthalmologist. My insurance company knows I need to see an ophthalmologist. Some people reading this post will now even know how to correctly spell ophthalmologist! Yet if I just went to an ophthalmologist, I’d have to pay the entire cost of the visit.
So instead I make a phone call. I do not call my doctor. I do not call my insurance company. I call my doctor’s receptionist, Mrs. McMeaneyPants III (that’s the name on her birth certificate, I think), and ask for a referral. She (reluctantly) fills out a form.
I have never — not once — even met my doctor, since I have not had any general health problems since signing up for this plan. Moreover, because Mrs. McMeaneyPants outright refused to let me fill out a patient history for his office to have on file in case I ever do need to see him, there’s no real record of me as a patient there.
I really feel like this is the medical equivalent to investing illicit funds in an off-shore holding company.
I know it all seems stupid, but most people don’t know a good specialist so they ask their doctor who they should see. Some people — like you — have a clear idea what type of treatment they need.
In my previous job, the health plan had some exceptions to the mandatory referral rules. Things like chronic condition, psycho-therapies, gynecology.
A more practical, less bureaucratic approach might be to only pay for a non-referred specialist if he/she attests their treatment is needed. That would put the burden on the patient (you) to be sure they’re doing the right thing.
I have no problem with the idea of getting referrals as they were intended. If I did have a complicated illness, or an illness I really weren’t capable of diagnosing, I’d expect my doctor to be able to point me in the right direction.
Where it all becomes silly is in cases like this, where following the rules as they were intended would require me visiting my doctor, who has absolutely no training or background in optometry, and asking him if I need to see an optometrist.