Tests and procedures self-referred to Providence too often? Local doctors ask
By Polly Keary, Editor
Twelve days before Christmas of last year, Marion Hamilton of Sultan was at work when she thought she was having a stroke.
“The whole left side of my face was paralyzed,” she said.
She wound up at Providence Medical Group’s walk-in clinic in Monroe, where she was told to go to Providence Regional Medical Center in Everett to get a CT scan.
She asked if she could have the test at Valley General Hospital, right across the street.
“They told me, ‘If you did that we wouldn’t know the results for a week or so. It could take forever to get the results. But if you go to Providence to get a test, we’ll get the results right away,’” said Hamilton, a no-nonsense woman who with her family runs East Teak, a hardwood retailer on U.S. 2 in Sultan.
So although she was nervous about driving in her condition, she drove to Providence.
She found she had a form of palsy from which she recovered, but now she wonders if driving to Everett was the right thing to do; if staying within the Providence electronic medical records system was worth driving half an hour in a frightening medical condition for a test she could have gotten 100 yards away.
She is not alone in being concerned about whether Providence is always right when referring to specialists and tests within its own system; several local doctors have protested about such referrals publicly and believe they are being squeezed out of private practice.
But Providence says there is no internal directive for primary care doctors to push patients to use Providence services exclusively, and they say that when they do suggest staying within their system, it is because they believe Providence will provide better or faster results.
“Continuity of Care”
Providence professionals freely say that they do try to convince patients to stay within their system for a couple of reasons.
The one most often cited is Providence Health and Service’s new $1 billion electronic medical records system, EPIC, which digitizes and stores all patient medical information in a way that makes it easily retrievable and viewable by any doctor in the multi-state Providence system, a benefit they call “continuity of care.”
But exactly how valuable that is to patients is a matter of some debate.
March 20, a letter from long-time Snohomish cardiologist Lawrence Haft, a member of Western Washington Medical Group, appeared in the Everett Herald, accusing Providence of trying to lure long-time patients away.
“I was surprised to learn that Providence Physicians Group has been contacting my patients and suggesting to them that they sever our long-standing ties and switch to a recently-hired Providence cardiologist,” he wrote.
Thomas Yetman, CEO of Providence, replied in a letter that Providence was doing that because patients could benefit from the hospital’s new electronic medical records system.
“As professionals entrusted with the health and well-being of those we serve, we feel a moral obligation to inform our patients of the advantages of a single, shared electronic health record,” he wrote, along with co-author Jeff Hambleton, the hospital’s chief medical officer. “It’s important that our patients understand the choices they have, and that by choosing Providence for their health-care needs, they can have the security and confidence that a single electronic health record affords.”
Sometimes, he went on, having a shared medical record in between all parts of the hospital can be a “matter of life and death.”
It is true, said Jerome Tillinger, CEO of Western Washington Medical Group, that different hospitals have different records systems (EMRs) and that few interface well. It is as if one hospital wrote all files in Word, and another in TextEdit, and they were unable to open records sent between them.
Currently there is no common system all hospitals can share.
But that doesn’t mean hospitals and doctors can’t share information, he said. Some services, like Radia, make it easy to share information between facilities. And doctors have always had to work with doctors in other systems.
“They’ve been doing it for decades,” he said. “Providence says they should break the relationship between them and their physician because the EMR system is compelling, but I would challenge them to provide statistical data to prove that.”
Sky Valley doctors say they are losing business
Mike Eickerman came to Monroe to practice surgery in 1996, originally at the urging of Providence, ironically enough, because Providence worried that too many of their Monroe patients were having to travel to Everett for surgeries.
“That’s how I ended up in Monroe,” he said. “They wanted someone to commit to the community. They wanted what could be done in VGH to be done close to home.”
He had a great relationship with Providence for many years, he said, and the clinic would refer patients to him whenever possible.
But recently, he said, things have begun changing. Sky Valley people are now being referred out of the area, he said.
“People from Monroe, Sultan and Gold Bar are directed to Everett when they could have the same care here, if they wanted to have it here,” he said.
He is getting dramatically fewer referrals in recent months, he said.
“I’ve seen a lot of referrals go down in the last six months, and really a lot in the last three months,” he said. “My volumes have gone down substantially, over 50 percent.”
It’s not just him, he added.
“At [Valley General] the number of ancillary procedures, MRIs, CT scans and ultrasounds have all gone down substantially,” he said. “What has really taken a real downturn in the last three to six months is radiology, enough that people are getting laid off. But the equipment is the same, and in fact it’s the same radiologist.”
Other doctors say they aren’t getting the referrals they once did, or that they get none at all.
Mark Raney, physician and operator of Sky Valley Family Medicine, Sultan’s only medical clinic, said that when Sultan residents are discharged from Providence, they get a form that says that, when possible, the hospital has contacted Raney about follow-up care.
“We have yet to receive a single call,” he said. “We’re available 24/7 and none of us have gotten a call.”
And recently-retired vein specialist Chuck Strub said that his referrals dropped markedly in his last year.
“Since about September of 2011, we saw referrals from Providence plummet to nearly zero, and I really know because I kept track of all the referrals I got,” he said.
That presents a serious financial challenge to both the local specialists and Valley General, because the specialists use VGH facilities for procedures, and both doctor and hospital get paid.
Eickerman said that he is worried for his career in Monroe.
“I might have to look for other options in the area that will allow me to stay here,” he said.
Providence says they only refer in patient’s best interest
Deb Nalty, primary care physician and medical director of Providence’s clinic in Monroe, says that there isn’t any Providence policy pressuring Providence primary care doctors practicing at the Monroe clinic to refer all patients to Everett for tests or specialty care.
“We order everything from Valley General, unless the patient prefers somewhere else or we need something stat, or if we need a higher level of imaging,” she said.
Providence has a couple of things Monroe doesn’t, she said.
The MRI in Everett is more powerful, she said. And getting test results, especially on nights or weekends, is faster at Providence.
“It is very common for us to be quite frustrated ordering advanced imagining from Valley, especially in emergent situations,” she said. “It is markedly more difficult than at Evergreen or Providence.”
And as far as referring to Providence specialists, she said, when it’s appropriate, it only makes sense.
“It’s a business,” she said.
Indeed, the way most hospitals make money is by having their own primary care doctors who can refer to their own specialists.
There’s nothing wrong with that at all, said Tillinger of Western Washington Medical Group.
“It’s entirely appropriate to refer within the same practice,” he said.
There are often benefits to the patient, too, beyond records systems, Nalty said. She likes it when she can physically be in the same building with other doctors who are seeing her patients.
But 40 percent of all her referrals in fact go to Evergreen, she said. The bottom line, she said, is that she will try to send her patients to doctors she trusts and hospitals that she believes will do the best job at whatever procedure is needed.
And if you can’t trust your primary care doctor to put your needs first, then you have the wrong doctor, she said.
“Do your homework”
The most important thing for people to know is that they can choose to go to Valley General for many tests and procedures, said Eickerman.
“The doctors at Providence, they are good physicians,” he said. “But people need to know they have a choice.”
Too many times, he said, people just trust their doctor implicitly and don’t ask questions or speak up about their preferences.
Nalty, too, said that patients should be assertive about their concerns.
“The bottom line is, you should do what your cardiologist says, but if they tell you to go to one hospital over another you should ask more questions,” she said.
No one knows that better that Marion Hamilton in Sultan. When she learned she had cancer of the larynx, her doctor told her she’d have to have emergency surgery to remove much of her larynx, followed by chemotherapy and radiation. Her surgery was scheduled within a matter of days.
But horrified at the thought of losing her ability to speak, she quickly sought another opinion. Hours from surgery, she learned of a much less radical procedure performed at another hospital.
She never had to get chemo or radiation, and the surgery left her the use of her voice. Four years later, she is cancer-free.
When it comes to choices over where to get tests done, or where to have more advanced procedures done, she said, the best thing you can do for yourself is get all the information and make your own choices.
“So do your homework,” she said.