Table 4. Issues Due to Cost of Care Management
Patients not willing to pay for care manager servicesCare manager: “Well, all of a sudden she got a bill for like a $120 … and that was the end of that. She told me that she would come back and see me when she got that bill paid off, but I don't look for her to call me up. … so that was one of my success stories you know that I was really kind of clicking along with her, and I was seeing regularly.”
Care manager: “And frankly I don't think that patients yet get that a nurse visit is worth any money. Now you and I know that a nurse visit can be packed with a lot more information, support, training, motivation than a provider visit, but the patients don't get that. They're not used to thinking in terms of paying a nurse for anything, so they don't value it.”
Physicians not referring to care managers due to concern about payment from the patientInterviewer: “So you were getting actual feedback from the patient saying I can't afford this?”
Physician: “Or a phone call where they called the front staff and they said patient cancelled visit due to cost. Yeah so I mean even if we have like 2 or 3 insurances that are on board, and say we want to get these people all the help they need because they cost us less money when their diabetes is well-controlled. Then we'll say fine.”
Receptionist: “I think [the patient] saw [care manager], and we billed for the visit. It was like $212 or $230 and [the patient] ended up getting the bill, and he was really upset about it … so I think that may have affected referrals. The [providers] are hesitant to refer because they really, our patient population down here isn't, you know we have a lot of Medicaid, a lot of indigent patients. So they're really hesitant to refer if they think the patient's going to get stuck with the bill.”
Problems of uncertainty about payment and what can be billedPhysician: “First thing they want to know though is how much is this going to cost?” Interviewer: “And then what do you say?” Physician: “I don't always know because I don't know what kind of copay they're going to have or what is covered. What isn't covered? And I can tell them I don't know, but my front desk will try to help find that out.”
Care manager: “I think that the whole money thing needs to be a little more clearcut from the beginning. A patient needs to know up front whether there's going to be a charge, how much of a charge there's going to be. When they're expected to pay it? In this state of the economy, people don't like surprises, and when the front desk staff says well we'll have to submit it and see what they pay. People don't want to know that.”
Receptionist: “Who qualifies for what? What insurance pays for what? What codes get done? What does [the care manager] bill? How does she bill it? If she doesn't bill it, is the patient going to get this? Do they have to pay a copay? Can they be seen 2 visits in 1 day? That's a disaster. If they have a blood draw the same day as [the care manager], [the care manager's] the rendering, which she's not an MD, so she can't order blood. She can't order micro albumin, so then it has to have 2 encounters which link together, and then it has to be processed backwards, and it's a nightmare.”