By Steve Twedt

After a patient’s pelvic exam Pap test results came back abnormal last January, the next step medically called for a procedure to determine whether the abnormal cells indicated a treatable infection — the most likely possibility — or something more serious, including a developing cervical cancer.

Ten months later, gynecologist David Deitrick said his patient is still deciding what to do.

The problem is the patient’s insurer, one of the national carriers in the Pittsburgh market, says her plan does not cover the procedure if it’s done at an outpatient surgical center.

She could have it done at Jefferson Hospital in Jefferson Hills, where Dr. Deitrick sees patients, but then her bill would be hundreds of dollars more, including facility fees and other hospital-related costs.

So she waits — hoping either to convince her insurer to change its mind or to save enough money to be treated at the hospital. Dr. Deitrick’s office checks in with her monthly.

It’s a scenario that’s playing out more frequently these days: Physicians caught in the middle between the care they’ve recommended and what the patient’s insurance will cover.

As high deductible plans become more prevalent and provider networks narrow, it now often falls on the doctor’s office to check network eligibility, to ask for upfront co-payments and to chase down overdue bills.

“It’s difficult to talk to people about it. It’s actually embarrassing,” said Dr. Deitrick, who steps in as president of the Allegheny County Medical Society next year. For people used to looking out for their patient’s best health interests, bringing finances into the conversation goes against the grain.

And, as his patient’s story illustrates, it sometimes impacts patient care.

A few weeks ago, a journal released its seventh annual national “Great American Physician Survey” of its readers, which revealed doctors’ deep pessimism about trends in healthcare delivery.

One question asked the 1,315 responding doctors to indicate, on a scale of 1 to 5, the degree they are happy with the direction healthcare in America is going.

The responses averaged a dismal 1.86.

“They’re not happy with the third-party interference, with insurers kind of holding them over the barrel, nickel and diming them,” said Gabriel Perna, managing editor for the Norwalk, Conn.-based journal.

Those insurers include the federal government which, beginning next year, will institute a new Medicare payment formula based on quality and cost measures that physicians fear will reduce reimbursements for many of them who treat Medicare patients. The federal Medicare program provides health coverage for more than 50 million people 65 and older or with certain disabilities.

This follows a series of other stressors on a physician’s practice, including the push to adopt electronic medical records and continuing haggles over whether a two- or three-day hospitalization constitutes in-patient care — which pays one reimbursement rate — or simply an observation — which typically pays less and may require the patient to make up the difference.

Insurers make that determination, Dr. Deitrick noted, but it’s the doctor’s office that often fields the angry calls. “They make it seem like it’s our fault.”

The survey reflected those frustrations: 40.5 percent said higher deductible payments and patient costs “represent the largest barrier to patient care,” followed by the simple high cost of care at 20 percent, for a total of 60.5 percent pointing to finances impacting patients’ care.

Third-party interference was their “biggest frustration with being a physician, according to 37.4 percent of the respondents, more than double any other reason cited.

And, while physicians split about evenly on whether the federal Affordable Care Act has been mostly good or “a disservice” for Americans, the growing challenge of collecting deductibles was the most common reason given for how the ACA had affected their practice.

For all the venting by physicians, though, Mr. Perna said one response in particular caught his attention: 62.1 percent of the physicians surveyed said, “if the circumstances were favorable,” they would be open to switching to a direct pay model that did not accept insurance.

“Years ago,” he said, “people would not even consider such things.”