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Feldman ’15: The gatekeepers of health

By
Opinions Columnist
Wednesday, October 1, 2014

Certain parts of life are often taken for granted. People do not think about their ability to breathe unless they are having difficulty doing so. One doesn’t consider the difficulty of walking up a flight of steps until he or she sprains an ankle and it hurts too much to support any weight. It is difficult to fully appreciate a completely healthy body. Thus, when a person suffers an illness or injury, he or she doesn’t really know how to treat it. Especially for some of the more rare injuries, such as managing to get a finger caught in a door at a job interview like I did, new patients often don’t know where to seek medical treatment — or if it is even necessary. Health Services, with its gatekeeper model derived from the Affordable Care Act, exemplifies aspects of the coordination that already exists in some current treatment plans. But it also showcases the need to further streamline the medical treatment process.

Health Services offers a wide variety of services ranging from emergency care and walk-in appointments to immunizations and pharmacy services. These services constitute the brunt of medical treatment one can find in a primary care facility or emergency room. Health Services uses these resources in accordance with principles underlying the ACA: The ACA aims to make health care more accessible to every citizen, decrease the cost of the health care system and improve overall quality of patient care.

Health Services unquestionably meets the standard of accessibility. Its location in Andrews Hall allows students to receive medical care just a short walk away from the Sharpe Refectory, so students in need of medical assistance can simply stop on the way to lunch. If an individual has a more pressing medical condition, he or she can often be seen the same day. One does not have to take a bus off campus to one of the several hospitals in the area for an x-ray either — Health Services has a machine adjacent to its waiting room. While this ease of accessibility is uncommon for many student patients trying to schedule an appointment, it is exactly the patient access the ACA intended.

Health Services also decreases the cost of overall health care system by pursuing the ACA’s emphasis on prophylactic measures. The facility offers education about certain diseases and free vaccinations against diseases like influenza, tetanus and human papillomavirus that are more expensive to manage than the initial cost of the vaccine.

Health Services’ gatekeeper model increases efficiency, allowing improved access and affordability for the health care system. Students can simply go to Health Services and allow a nurse practitioner to direct them to a specialist elsewhere if necessary, instead of deciding for themselves whether to seek an orthopedist, the emergency room or just ice for an injury. How else is one supposed to know where to seek treatment without prior experience? A gatekeeper streamlines the process by eliminating wasteful visits, which makes physicians more accessible to those in need while limiting the frequency with which insurers unnecessarily pay providers.

A gatekeeper model aims in part to coordinate the medical system. As the theory goes, the system would be more efficient if a single entity — the gatekeeper — managed an individual’s affairs, instead of having each medical provider maintain individual records.

But this is one area in which I found Health Services to be extremely lacking. Without a system yet in place to properly coordinate medical treatment with insurance providers, Health Services’ current structure remains insufficient. I sought treatment for a potentially injured finger and was recommended an X-ray. But although I have my own private health insurance plan that has covered X-rays in the past, Health Services does not accept any insurance — University or private — to cover X-rays. Instead, if patients want to be reimbursed for the services, they have to either contact their insurance provider prior to the procedure or risk contacting the insurer and sending over the receipt after the procedure without a guarantee it is covered under the plan.

Neither option follows the guidelines for an effective gatekeeper model. While Health Services might save money by refusing to accept insurance because it does not expend resources or time contacting insurers, it adds undue stress on the patient. Students also pay Health Services for a reason. Even if students opt out of the university health coverage to use private insurance instead, there was still a $356 fee added to the tuition bill for this semester.

Most students have never called their insurer before and know little about their coverage. Unless a student has a medical condition that requires frequent visits, it’s just not something they need to know. Why should the person who doesn’t fully understand what is happening and has never been involved with a similar situation be responsible for doing that research? Not only does discontinuity in treatment place a burden on the student, but it can also harm communication, which may lead to substandard care.

The patient may also be in no physical or psychological condition to do the legwork. When I injured my finger, my sole concern was how crooked my finger looked, not the benefits and detriments of paying out-of-pocket for medical treatment. All this process did was slow down the actual treatment, which helps no one.

Requiring a student to coordinate with two distinct parties who are not in communication with each other places an obstacle in front of the gatekeeper model. The idea of the gatekeeper model is to keep the gate open and then have the gatekeeper direct the patients down the correct path. In this current system, patients are unreasonably expected to have a map of these pathways and be responsible for their insurance plans themselves. Health Services needs to work towards coordinating this care for its students. It should expand its role to work directly with both patients and insurers, even if that means expanding its staff to accommodate the additional workload.

In the grand scheme of things, my finger swelling up for an extra hour isn’t the worst thing in the world, but that doesn’t mean there aren’t worse consequences for other patients if their care is just as uncoordinated. Coordination of care and the gatekeeper model are essential for sustainable health care services in America. But until these two entities truly become the same, medical treatment will continue to lack total efficiency and patients will continue to suffer because of it.

 

It took Andrew much longer than normal to write this article with only nine functioning fingers so it may take him a while to respond to emails sent to Andrew_feldman@brown.edu or tweets to @Amfeldz.

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