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Great idea vs great idea

September 28, 2011

Sometimes great ideas have the unintended consequence of obstructing other great ideas.  Case in point– medical centered homes vs extended hours for primary care services.

Last month I had a conversation with Dr. Michael Fine, the Director of the RI Department of Health. He told me about his vision for expanding access to primary care. That vision included having doctors’ offices open at night and on the weekends to avoid costly and unnecessary trips to the emergency room.

Dr. Tanya Becker, a women in my running club who’s also a pediatrician, is trying to do exactly that- offer primary care for children after traditional doctors’ offices have already closed.  She says there’s a real need for this kind of care, especially for working parents-

That parent who picks their child up from day care who might just have a rash or might just have some diarrhea,  if that day care or that school says we can’t have your child return until they’ve seen a doctor… the only two options are to one- go to the emergency room for something that’s non emergent or go to an urgent care clinic for something that’s not urgent.

Both the emergency room and the urgent care center charge more than a primary care office, so parents and their insurer are paying more for services that should be reserved for  extreme health problems. Dr. Becker says there’s another problem with relying on emergency rooms for milder health issues-

Through the emergency departments, these people are triaged.  So if they’re just coming in for a diaper rash, they could sit for hours and hours waiting to be seen.

To resolve those issues, Dr. Becker wants to open a pediatric center that offers primary care from 5pm to 10pm.

But she’s encountered a bureaucratic roadblock.

What’s the problem? About 50% of her patients receive health insurance through RIte Care– the state sponsored program for low income families. But RIte Care will only pay doctors who’ve been designated as the child’s “Primary Care Provider” or PCP.

Deb Florio with the Department of Human Services says there’s a logic to this. Rhode Island wants children and adults to have a “medical home”- a place where they get consistent care. Requiring a PCP means a single doctor has ownership over the patient’s overall health needs. The physician can keep a closer eye on things like immunizations and chronic diseases.

But that also means if Dr. Tanya Becker wants to offer after hours primary care to all children in the state,  she won’t get reimbursed for the ones on RIte Care. That’s a problem when half of the children she serves are low income.

Becker says she’s in complete support of the medical home model, and her center would compliment, not threaten that doctor patient relationship.

I’m saying let’s provide primary care for people that don’t have a choice but to go after hours because their physician’s office is closed.

Becker says she’d make it a practice to communicate with primary care doctors about the services their patients receive at the pediatric center. That’s a courtesy she doesn’t usually get when her patients go to the emergency room or an urgent care clinic.

I’ve asked Neighborhood Health Plan if there’s any flexibility in the way it processes reimbursements so Becker can get paid for offering these services. The company sounds willing to figure something out. Tom Boucher with Neighborhood says-

We think Dr. Becker is a great doctor, are proud to have her in our network and are interested in her innovative pediatric urgent care concept. Conversations are ongoing with Dr. Becker and we are looking at how we can work together to meet the needs of the community.

In the meantime, Becker is looking at relabeling her center as a “walk in clinic.”  Perhaps that title will give her more billing options. Either way, she’s not giving up.

Nothing will get me down. I’ll continue to make phone calls and write emails and do my own personal research to see how I can make this happen.

Here’s hoping both great ideas can eventually exist in harmony.

2 Comments leave one →
  1. ninjanurse permalink
    September 28, 2011 10:53 pm

    Nice post. It will be great if the doctors and NHP can work out a relationship that makes it easier for people to get good care.


  1. A happy ending for great ideas « The Pulse: health care in RI

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