Diet Coke with Two Straws: The Story of an Armchair Stalker

Matt Freeman DNP, MPH

 

“This is hard to talk about,” said Tony, looking toward the floor.

It was Tony’s second visit. He had come in with a somewhat benign visit a month prior, complaining of shoulder pain. He was perhaps “testing the waters,” and had come back to discus his true concerns.

I recall him as largely nondescript: a 30-year-old manager of a large retail store. He had a condominium in a solidly middle class neighborhood, proud to be close with his family and wife. He told me how he was looking forward to playing football with his brothers.

“It’s so personal.” Tony gazed at the floor. His eyes starting to tear.

This was familiar territory for me. I had my money on erectile dysfunction, a diversion from marital fidelity, a gambling problem, sexual thoughts about about other men. None of the above. I was entirely unprepared.

“I wear women’s clothes.”

This was still not an overwhelming story for me. I had worked with heterosexual cross-dressing men before.

“My wife’s clothes.”

This just got a bit more complicated.

 

“It’s because of Jill. Jill Payne.”

“Who?

“Jill Payne. WNTN?”

 

I was stumped.

 

Exasperated, Tony explained that Jill Payne was a local news anchor. He was shocked that I had never heard of her.

Set

Tony explained that he had been going with his wife to purchase clothes for her that matched those of Jill Payne. She rarely watched the news, so she did not recognize that her clothes matched those of the news anchor.

In his wife’s absence, he would wear the dresses and suits while scouring the internet for photos and videos of Jill Payne.

Tony shared a small scrapbook of Jill Payne photos. Almost combusting with anxiety, he began to spill endless details of Jill Payne’s life: where she was born, her favorite restaurants, the names of her children.

As he composed himself, I asked a few critical questions. Tony had no interest in hurting Jill Payne. He knew her neighborhood but not her house, and he did not have sexual thoughts about Jill Payne. He also had no thoughts of being “trapped” in a man’s body. Tony just wanted to feel as close to Jill Payne as possible.

Tony initially seemed to hope that I would help facilitate further connection with Jill. He explained that Jill’s husband was a physician, and perhaps I knew him. Furthermore, was under the impression that Jill’s husband was Jewish, and he began questioning me about my religion, hoping to glean as much information as possible. I deflected.

WWNY

My first concern was for Jill Payne’s safety. Tony denied any plan, intent, or means to hurt her. He denied any attempts to visit her home or the television station. The action of stalking was not part of his life, at least not for the moment.

I felt desperate to call Jill Payne. But I could not. From a confidentiality standpoint, I had no grounds to breach the provider/patient relationship. To make a call to Jill Payne, Tony would need to have expressed a clear intent to harm her. Tony did not meet the legal criteria for a so-called “Tarasoff Warning,” or duty to warn a potential victim of violence.

I was unsettled, and I collaborated with a physician and two psychologists. They all agreed that the best course of care would be to find a therapist for Tony, maintain rapport, and monitor his stability.

 

“Most Likely to Be Stalked”

Jill Payne has probably gone through this before. Amy Jacobson, a news broadcaster, said, “Everyone has a crazy guy. It’s expected.”

Although statistics are hard to find, women on local news channels have been described as the “most likely to be stalked.” It has been described as a “job-related hazard.”

Park Dietz MD, PhD, MPH is a forensic psychologist known for his testimony in high profile murder and stalking cases, including John Hinckley Jr. and Jeffrey Dahmer. Dietz’ view is that those who stalk news reporters are seeking status, fame, and glamor… a means of compensating for his own sense of self.

Dietz characterizes the typical news reporter stalker as single, male, under- or unemployed, lacking intimate relationships, and with a poor sense of self.

Indeed, Tony was a lonely man. Although married, he worked at night while his wife worked during the day. Lacking intimacy and purpose, he did not just aspire to have Jill Payne’s possessions. He aspired to be Jill Payne.

 

Artificial Intimacy

I remembered an ad for the local news when I was a child. The female half of a news anchor team spoke of her adoration for the male anchor. “He always brings me my Diet Coke the way I like it… with two straws.”

A neighbor was visiting a city across the country and was taken by an ad for the local news team. “He always brings me my Diet Coke the way I like it… with two straws.” The two straws were an invention of the national network’s marketing office.

DietCoke

 

Local news anchors are touted as part of the community. They are neighbors.  They have the illusion of being friendly, familiar, and approachable. And all of this is engineered through advertising. The “two straw” preference was somehow a way to make the anchors seem nonthreatening and amiable.

This is not to say that Jill Payne is anything but pleasant; I would have no way of knowing.

Family TV

 

The frequency of exposure compounds the situation. The local news anchor is in one’s living room or bedroom at least five days a week. She closes her broadcast with “Thanks for joining us. See you tomorrow.”

Tony knew that Jill Payne could not see or hear him. But she was a part of his everyday life. In fact, her current broadcasting schedule is weeknights at 5:00, 5:30, 6:00, and 11:00.

Michael Zona MD, a psychiatrist in Boulder, Colorado, explained that the most beautiful women are not typically the objects of such affection. Instead, it is the “girl next door.” The obsessed stalker may find that it would be within the realm of possibility that this woman would want a relationship with him.

A higher-profile celebrity in Manhattan or Hollywood might have appeared to be “off limits” to Tony. Jill Payne’s hometown sensibility and geographical proximity made her a more appealing target.

Stations

Obsession as a Function of Narcissism

Reid Meloy PhD, a forensic psychologist, describes a “narcissistic linking fantasy.” This can actually be a part of healthy human behavior: the thoughts of love, admiration, being liked, and complementing one another. The self-serving need for love and admiration are not pathologic.

Narcissistic linkage fantasies become troublesome when the fantasy involves someone who cannot reciprocate. Jill Payne never knew that Tony existed. But he could view this as a form of rejection. Although—to my knowledge—he never contacted her, he might find a postcard from the news channel to be dismissive. Jill was not recognizing the depth of his affection. He had spent a major proportion of his life devoted to Jill; she would not reciprocate.

Jill Payne comprised Tony’s sense of self, so anything that could be perceived as a slight by Jill would be an attack on Tony’s already damaged self worth.

 

From Obsession to Stalking

Tony was an “armchair stalker.” He never admitted to following Jill Payne, meeting her, or making plans to do so. But there was certainly a risk.

Although the prediction of future violence is almost impossible, I doubt that Tony would have ever tried to harm Jill Payne. In fact, I think that his fear of rejection was somewhat protective (for Jill) since he would do everything possible to avoid a slight from Jill.

But if his life disintegrated further: if his marriage dissolved, he developed a mood disorder, or other instability, he was certainly at risk for irrational or dangerous behavior.

ActionNews

After the News

I doubted that Tony was struggling with his gender identity nor with wearing women’s clothes. His true distress was about an impossible love, and obsessional  behavior. But he was at ease talking about his obsessional behavior as a function of cross-dressing. It was tangential way for me to get him connected with a psychologist. I consulted by phone with a psychologist who specialized in gender issues, and he was willing to consult with Tony. The psychologist was out of Tony’s insurance network, and he could not afford the cost of the visit.

I moved to a new city not long after I started working with Tony. I transferred Tony to the care of a colleague. He never followed-up.

I searched the internet for news stories under Jill Payne’s real name and the word “stalker.” No hits. She is still an anchor ten years after I worked with Tony.

 

References

Meloy R. The Psychology of Stalking: Clinical and Forensic Perspectives. Cambridge, MA: Academic Press. 2001.

Wise J. Most Likely to Be Stalked. Psychology Today. 8 October 2010.

 

©2016

All images public domain

The names “Tony,” “Jill Payne” and the station “WNTN” are pseudonyms.

 

 

 

 

 

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In and Out of Network: The $900 million annual cost of provider credentialing

Matt Freeman DNP, MPH

“Are you ‘in networkwith Blue Cross? Cigna? Humana? UnitedHealthCare?”

My office gets these calls all day, every day. According to The Washington Post, the average wait time to see a family practice physician is 66 days in Boston, 24 days in Atlanta, and 23 days in Seattle. Dallas was the lucky city with an five-day wait.

New medical schools have scrambled to open; there have been increased enrollments in physician assistant and nurse practitioner programs. Professional schools are working harder than ever to recruit, educate, and graduate primary care providers.

Unfortunately, new primary care providers face massive barriers with insurers.

A licensed healthcare provider cannot just send a bill to an insurance company and expect a check in the mail. Insurers require that the provider undergo a credentialing process, which officially takes about 90 days, but it can take 180 days or more. Or the insurer may be “closed” and not allow the physician, physician assistant, or nurse practitioner to join the network at all.

 

Why Being “In Network” Matters

Even if seeking care for myself, I look to see if the healthcare provider I wish to see is within my insurance network. I am well aware that I have a $4,500 deductible and “in network” providers, and a $6,900 deductible and 50 percent co-insurance for “out of network” providers. In other words, I have to pay half the cost of the patient visit up to $6,900 if I see someone outside of my insurer’s network.

For the first time, the federal government is helping consumers find this information as well: beginning in January 2016, www.healthcare.gov will now allow consumers to find specific clinicians before deciding on a health plan to join.

waitingroom2

 

What is Credentialing?

Credentialing is the process used by health insurers to permit a healthcare provider to become a part of their “network” or “panel.” It involves a review of the provider’s credentials and approval of a committee. It is estimated to cost $900 million annually. (That figure is limited to physicians, and does not include physician assistants or nurse practitioners, who go through the same process.)

Insurers rightfully want to provide their enrollees with high-quality care. They seek to verify that the providers “empaneled” in their networks are appropriately educated, board certified, and do not have licensure sanctions or malpractice cases indicative of a pattern of poor quality of care.

The insurers state that they depend on “primary source verification,” meaning that they will not accept a photocopy of a diploma, transcript, or board certification. They want the information directly from the academic institution or certifying body.

Although this appears to be a logical step to prevent fraud, insurers are overlooking the fact that state boards require this information in order to issue a license. For example, my state licenses required a copy of my transcripts, proof of an internship, proof that I passed all my of board exams, written letters from the academic programs from which I graduated, fingerprints to be processed by the FBI, and a search of the National Provider Data Bank for licensure sanctions and malpractice cases.

If all of this is required to be licensed, why would an insurer need to repeat the process? Thus far, nobody has been able to answer that question.

 

The Process Starts Over Every Time a Provider Moves.

After months of “primary source verification,” a provider faces the same process from the beginning if he or she moves practices. Insurers tie each provider to a federal tax identification number. The minute that changes, credentialing has to start over.

Insurers may have specific requirements like hospital admitting privileges, “on call” services, accommodations for disabled individuals, and so forth. Likewise some practices offer a wider array of services than others, but these are small changes. Why would an insurer need to re-verify that a degree, certification, or license have been issued just because a provider moved to a new practice?

I have been re-credentialed by insurers at least three times even though my degrees, certification, and license did not change.

 

The Failed Solution

In 2002, the Universal Provider Datasource began. This gave healthcare providers and insurers are central databank of credentialing documents: certifications, employment history, diplomas, licenses, and so on.

The idea was that a provider has a unique code with the databank, and he or she then grants insurers access to his or her information. No need to fill out page after page of the same questions.

But it actually serves no clear purpose. The Universal Provider Datasource, now part of the Council for Affordable Quality Healthcare is a self-report system. Clinicians submit their information, attest to its legitimacy, but it is not verified.

Instead of streamlining the system, it just adds an additional step to a cumbersome process.

 

Even “Primary Source Verified” Information is Wrong

I am “in network” with one particular large insurer. Patients can select me as their primary care provider, and I show up in their list of available PCPs. But the information listed is wrong. Despite careful “primary source verification,” I am listed in the wrong specialty, and the system shows me as having been in practice for three years (I have been in practice since 2004.) Perhaps their “primary sources” included imagination and fuzzy math.

I suggested that they change my specialty in particular (they listed in my family practice, which I am not.) They did not change anything. It is unfortunate that I appear less experienced than I am based on their web site, but perhaps I should be willing to accept that as a compliment to my youthful appearance.

 

Pills

 

The Closed Network

A number of large insurers have shut the door to new primary care providers. Despite the shortage, these companies have decided that their patients should pay more.

For example, two insurers in my area are “closed” to new providers. The refrain I often hear is, “I called my assigned primary care doctor, and the wait to get in was three months.” It’s just as common as, “The office said that they will not see me because I have not been in for 18 months.” That leaves the patient with the option of paying the higher costs of an urgent care, the emergency department (for a non-emergency), or the expense of seeing an “out of network” provider, which is typically double the out-of-pocket cost.

When I looked at one particular “closed” network, I searched on their web site for primary care providers within 15-mile radius. Most of the names were listed two or three times, so it took a while to filter the list. Then I cross-checked the names against the state registry: one had a cancelled license and lived more than 2,000 miles away, one specialized only in geriatrics, another was a kidney specialist, several were cardiologists. Good luck finding an actual primary care provider.

 

Closed Networks Erroneously View Primary Care Providers as Interchangeable

The relationship between a patient and his or her primary care provider is reassuring, potentially life-saving, and a critical component of disease prevention and management. Everyone has different needs: some primary care providers specialize in certain areas: women’s health, people with HIV, patients who speak a primary language other than English, the elderly, LGBT populations, the hearing impaired, etc.

Although insurers claim that they “consider” providers with special skills or experience for closed networks, this is—at least anecdotally—untrue.

 

Is this this Anticompetitive?

Yes. The system favors large conglomerates.

The balance of power lies with the largest provider groups and healthcare institutions. For example, when hospitals merge, they end up with two departments offering the same service: two groups of surgeons under the same umbrella holding company. The two provider groups have greater bargaining power with insurers.

Established practices do not want the networks to be open either. For example, a study of Florida hospitals demonstrated marked price increases beyond inflation and without accounting for changes in quality of care.

Insurers could also argue that they may open networks based on patient quality data. A closed network might be swayed into accepting a new primary care provider if he or she demonstrated high marks for meeting the standard of care for diabetic patients. But what if the practice has comparatively few diabetics? Or what if the practice inherits a large number of poorly controlled diabetics, and the patients’ data will give the illusion of substandard care.

 

 

Financial Motivation for Fewer Credentialed Providers

Insurers have great interest in keeping their networks small. If there are too many providers, the insurers might face the threat of demand for higher compensation. In 2002, a law suit against Aetna, Anthem BlueCross/BlueShield, and Humana was filed by physicians in Cincinnati. The physicians argued that they were reimbursed below acceptable rates. Humana settled for $100 million and agreed to increase its reimbursements by up to 30 percent.

An even larger network would have meant even greater bargaining power against Humana, and an increased threat to their ability to reimburse below the market rate.

 

Failure of Antitrust Legislation

The courts have been reluctant to take action against anti-competitive action by insurers. Some states enacted “Any Willing Provider” legislation, which mandates that any qualified provider must be allowed to participate in a network. But a decision by Justice Scalia argued that the Employee Retirement Income Security Act (ERISA) pre-empts “Any Willing Provider” laws. Therefore “Any Willing Provider” laws in 27 states apply only to state-regulated policies, not self-funded insurance plans (those typically offered by large employers.) Furthermore, in many cases, the “Any Willing Provider” legislation is limited to pharmacies and pharmacists.

 

How Could This Be a Threat to Public Health?

1. Delays in diagnosis and treatment

Imagine that you or a loved one has an early, brewing pneumonia: fever, chest pain, maybe a little short of breath, profound fatigue. If treated promptly with inexpensive antibiotics, it will not be pleasant, but it is certainly a survivable condition.

If the wait time is anywhere from five to 66 days, that could mean delayed diagnosis, delayed treatment, and the results could be life-threatening.

2. Excess Cost as an Impediment to Care

In the pneumonia scenario, one could argue “that’s why there is urgent care.” True, urgent care clinics and “convenient care” clinics (like those inside pharmacies and supermarkets) should be able to diagnose and treat pneumonia.

I had a look at the cost of going to one of these clinics. I searched on www.healthcare.gov for unsubsidized plans available within my ZIP code. I picked the first three plans from three different insurers.

  • Plan one: urgent care is not covered at all. It is considered a “non-emergent” use of an emergency facility.
  • Plan two: 20 percent co-insurance (in-network urgent care) 50 percent co-insurance (out-of-network.) The same service in a primary care office has a $10 copay.
  • Plan three: $50 copay per visit. The same service in a primary care office has a $30 copay.

Walgreens Healthcare Clinic lists its prices as $89 to $129 for evaluation and management of an illness. Depending on one’s insurer one may or may not be able to recover some of the expenditures from a visit to a “convenient care” clinic.

UrgentCare

 

3. Fragmentation of Care

Since credentialing starts over every time a provider moves, a healthcare provider cannot necessarily take his or her patients along. For example, say that a family practice physician is in a struggling group practice. She decides to break off from the group and open her own practice. Patients will have to wait until the physician is re-credentialed in her new practice. Even worse, if networks are closed, her patients will have to find a new family doctor, and they may face delays in finding the care they need.

4. Misused Funds

$900 million per year in credentialing costs is an unthinkable expenditure of healthcare dollars. The expenditure is often redundant, incorrect, and needlessly time-consuming. A “Gold” health insurance plan is estimated to cost $4,360 annually for the average person. If we standardized credentialing, we could translate that $900 million to “Gold” coverage for two million Americans, or reduce the deductibles and copays for those with high deductible plans that individuals and families cannot afford. We would also provide those consumers with access to a wider network of providers, offering timely care and—one hopes—fewer complications.

 


Potential Solutions

1. The infrastructure already exists.

The CAQH system already collects the requisite data for credentialing, but it is self-report. External verification companies, like Optum, could actually partner with CAQH to flag sections of a provider’s profile as independently verified.

My diplomas, therefore, would always have green check mark next to them, thereby eliminating the need for an insurer to check every time I move. After all, the day I earned by bachelor’s degree, my board scores, and my grade in pathophysiology are not going to change.

 

2. Centralize the “primary source verification” process.

Although insurers do not say so, it would be reasonable to assume that many contract with the same companies—like Optum—to conduct “primary source verification.” Why not allow transparency? Once a provider has been “verified” by one of these firms, there should be no need to repeat the process.

3. Charge an application fee.

Although I would hate to give even more money to insurers, motivated providers could be asked for—say–$100 or $150 for an expeditious review of their credentials.

Insurers concede that their “network” and “credentialing” meetings are held monthly. So this would meant that a new provider could be “verified” and ready to work within six weeks rather than six months.

 

4. Closed primary care networks imperil public health and impair consumer choice. Open the networks.

The shortage of primary care providers is well-documented, and this problem is going to get worse. Insurers should not be fearful of having to pay providers fairly if their networks grow.

Two of the “closed” networks had estimated operating revenues of $15.1 billion and $12.33 billion in 2015. Their financial security is not at risk.

 

References

Bernstein, L. US Faces 90,000 doctor shortage by 2025, medical association warns. The Washington Post. 3 March 2015. https://www.washingtonpost.com/news/to-your-health/wp/2015/03/03/u-s-faces-90000-doctor-shortage-by-2025-medical-school-association-warns/. Accessed 31 December 2015.

Bonfield T. Humana settles doctors’ lawsuit. The Cincinnati Enquirer. 24 October 2003. http://www.enquirer.com/editions/2003/10/24/loc_choicecare24.html. Accessed 30 December 2015.

Noble A. Any Willing or Authorized Providers. National Conference of State Legislatures. 5 November 2014. http://www.ncsl.org/research/health/any-willing-or-authorized-providers.aspx. Accessed 2 January 2016.

Porter ME & Treisberg E. Redefining competition in health care. Harvard Business Review. June 2004. Accessed 2 January 2016.

Potter W. Health insurers watch profits soar as they dump small business customers. The Center for Public Integrity. 25 January 2015. http://www.publicintegrity.org/2015/01/26/16658/health-insurers-watch-profits-soar-they-dump-small-business-customers. Accessed 2 January 2016.

ValuePenguin. Average Cost of Health Insurance (2015). http://www.valuepenguin.com/average-cost-of-health-insurance. Accessed 2 January 2016.

 

All photos public domain

©2016