Episode Transcription
Bronx and Brooklyn healthcare provider Dr. Nereida Correa discusses how the complexities of payment systems impacts her patients.
Published: March 24, 2021
Dr. Nereida Correa, who began her career as a registered nurse, became the first Hispanic woman to be named chair of the department of obstetrics and gynecology at Lincoln Medical and Mental Health Center, a large, hospital-based group practice in the Bronx. She is also an Associate Professor of Family and Social Medicine. As a women’s health physician in the Bronx, Dr. Nereida Correa has been active in mentoring and promoting cultural sensitivity to diverse ethnic communities. Today she discusses the changing face of healthcare payment systems with host Dr. Minerva Campos, together exploring ways in which recent changes can create additional barriers to care for vulnerable patients. Read the “Values Defined by Whom?” report at https://bit.ly/37YyWuJ
Dr. Campos: Hello and welcome back to the Health Disparities Podcast, a program of Movement Is Life Caucus. Movement Is Life is an initiative that aims to reduce health disparities, particularly in the areas of musculoskeletal and cardiovascular disease, mental health, and those disparities affecting women, black and Latino communities and populations living in rural areas. Thank you so much for joining us today. My name is Dr. Minerva Campos, representing the National Hispanic Medical Association as a member of the Movement Is Life Caucus. Before we introduce our wonderful guest, I want to mention that today we will complete our series inspired by the monograph created by Movement Is Life entitled, “Values Defined by Whom?” In which we have explored the question of what defines value in health care for its key stakeholders. We have explored the different payment models, including value-based payments, which of course is a type of reimbursement that rewards healthcare providers with incentives based on the quality of care they provide. The development of the policy calling for these payment models and the effects that these new payment models have had on the delivery of sub-specialty care. And today we will explore the effects they have had on the delivery of primary care. For those of you who are interested at the end of this podcast, I will give you information so that you may download the link to this really wonderful monograph.
Now, for the business at hand today it is my very great pleasure to introduce Dr. Nelly Correa, who is an associate clinical professor of obstetrics and gynecology and in women’s health, as well as in family and social medicine at the Albert Einstein college of medicine. She serves as the senior advisor of the first Hispanic center of excellence in New York state. And she co-directs the summer undergraduate mentorship program at Einstein. She has taught a required course for third year medical students, entitled, “Patients, Doctors, and Communities”, and is responsible for developing the section of the course pertaining to cultural competency, implicit bias and health disparities. This is something that Movement Is Life is so interested in. She served as the education core director of the Bronx center to reduce eliminate disparities in health. And she has an active private practice in the Bronx where she also serves as an attending physician at the North Central Bronx Hospital of the New York City Health and Hospitals Corporation. She is currently chair of the board of National Hispanic Medical Association and has been recognized by many organizations as you can imagine for her contributions to medicine, teaching and her community. So, Dr. Correa, thank you so much, welcome, we are just delighted to have you here today.
Dr. Correa: Thank you, I’m delighted to be here and it’s a real honor to do this podcast with you Dr. Campos.
Dr. Campos: You do a lot of different things within medicine, you’re in different locations, you’re doing different sorts of activities. Can you tell us a little bit about the different settings of work that you do right now?
Dr. Correa: I trained and grew up in the department of family and social medicine. So, that meant much of my medical care has a foundation in a person’s living situation and how they are able to cope with their lives. So, in addition to taking care of their health problems their illnesses or their preventative health issues, I also try to get involved with what their lives are like. So, in training and in teaching medical students and residents, I also try to convey to them the fullness that it is to be able to take care of somebody, not just for their medical needs, but to get to know them a little bit.
Dr. Campos: You’ve seen so much change in medicine since you’ve been involved, as we all have. And the payment models are something that has always been around, but they’ve begun to change pretty recently. Tell us a little bit about the payment models that you work within.
Dr. Correa: Everything changes, and sometimes everything stays the same. So, in my history I have taken care of people in public hospitals where there’s no issue around whether they have an ability to pay. And I have taken care of patients in private practice, which is the whole other end of the spectrum, where someone can prevent you from seeing a patient if their insurance card is outdated or it doesn’t match. So, as you can imagine, there are many frustrations with that system and in-between we have some of the new iterations, such as this new value-based healthcare system, where somehow criteria is being set up so that it will influence how much you’re paid or not paid and what their presumed quality of care is. So, that sometimes those match with my philosophy of taking care of people and other times I go head on trying to fight for the rights of the individual to be able to access healthcare.
Dr. Campos: That is very, interesting. So, you’ve told us something about this experience that you have with these payment models. What’s working in these models?
Dr. Correa: You know, for me, I’m a great advocate of the public hospital system. In New York City, we are very, lucky to have the Health and Hospitals Corporation that provides care to everybody regardless of their ability to pay and has as well as Medicaid, Medicare, and all of the payers, they have an HMO that belongs to the Health and Hospitals Corporation, and they also have a fee for service, they have a sliding scale. If somebody can pay $2, that includes everything the visit and going to the pharmacy and doing whatever needs to be done. So, that’s my favorite and I support it greatly because I think that it’s so important and especially in our new affordable care act and in some of the federal programs where immigrants are excluded, our hospital system does not exclude people because of their documentation or what is going on with them. So, luckily, we still are able to do that. In the practice, we are pretty much the same because we’re based in a community, so we take care of people that look like us and have similar issues. So, I grew up in Manhattan, was not an immigrant, but I came from Puerto Rico when I was five and we struggled and my parents certainly took advantage of the fee for service system and sliding scales and things like that, so that we could access healthcare.
So, my patients are very similar to me and my family and the way that I was and what we do in our practice is that we try you to have access to all the plans. And one of the things that is very frustrating is that there are many plans and each of them have their own criteria. So, if a person has a plan with one of the payers it may or may not match. So, what happens is they’ve had a doctor for many years and all of a sudden, the plan changes, and that doctor is no longer certified to provide services for that particular plan and then the patient has to go seek another doctor. So, in my work as a gynecologist, I run into a lot of women who are very distressed because they’ve been going to the same obstetrician-gynecologist for years, they delivered their babies, they did everything with them, and then, now, they have to switch to me, and they’re okay with switching to me, but it’s still very sad for them because they’ve had a long-term relationship with a physician that has been interrupted by the system.
Dr. Campos: You you’ve mentioned so many things that are talked about in terms of these sorts of payment models. One is, those are the complicating factor that when you see a patient, you literally seem to have to think about what kind of insurance or not insurance they have in terms of how you set out to work them up and take care of them. Not so much that you don’t do the standard that’s required, but it’s just that if they’re paying out of pocket, you have to give some consideration to that. If they have an insurance, they may have a drug formulary that you have to pay attention to. If there are certain kinds of managed care organizations, there may be some performance measures that you particularly have to think about that you might not normally even with some patients. So, how does that work with you? Do you find that you’re just getting used to doing that, or is it just every day a frustrating item?
Dr. Correa: It’s a challenge because, for instance if someone has a certain plan, there may be a formulary. So, you would prescribe something, and it may not be in their formulary and then because it’s an electronic prescription, you don’t even know whether they got it or not and then they get to the pharmacy and the pharmacy would say, well, you can’t have this. And you get phone calls saying, well, we don’t have this particular product, the other product is on formulary, or you may not hear anything at all. So, sometimes things fall through the cracks and I’ve had patients that I have given antibiotics to and follow up in a week and they come back in a week later and they haven’t taken anything. But the other thing is referrals because if you have to refer for certain procedures, then you have to look for physicians or practices that are in that group. So, that otherwise they would, again, reject the referral and the patient would not get. So, it does impact continuity of care and it’s always a challenge. So, it kind of requires that you keep close touch and one of the things, I’m not a great fan of electronic medical record because it takes so much time away from delivery of care. However, one of the things that it does try to do is coordinate care and make sure that if you send a referral, medical record arises with the referral and things like that. So, there are benefits, but it’s very frustrating and I think more frustrating for the patient than it is for me because I deal with it on a day-to-day basis, for them it is just a source of really frustration and anger. And if they have a medical problem that needs pretty immediate attention it’s a problem and sometimes you end up with the option of, well, then you have to go to the ER, because I can’t find anybody that’s in your plan and we can’t wait on this. So, it does impact on, when we talk about the value of the care that someone is receiving and sometimes it’s out of your hands.
Dr. Campos: Let’s talk a little bit about the patients, the monograph that Movement Is Life put together, took focus groups, and literally took them from different geographic areas of all women but different parts of the country, different perspectives, but bottom line is they pretty much all felt the same way and one of their biggest concerns about the healthcare right now had to do with just what you’re talking about. Doctors not really knowing about them. The communication aspect, the service aspect and also some of the costs. So, maybe you could tell us a little bit about if you’ve seen that within your own patients. What did they gripe about the most, what are they unhappy about the most?
Dr. Correa: Well, if they get in the door, they’re happy.
Dr. Campos: Oh, and that’s sad, isn’t it?
Dr. Correa: They mainly gripe about the amount of time it took for somebody to verify their insurance or to make sure they could be seen. But one of the things I agree with the focus group, that communication is key and one of the things that is really, important is to make sure that you talk, and you listen to where your patients are when they arrive in your office. Especially, these COVID times, the first thing I asked my patients, no matter what the purpose of the visit is, how are you and how is your family? Is everybody okay? And then, go from there and often they have a lot of times they’ll have family. I have patients from the Dominican Republic, and they have relatives that have COVID or are ill and they can’t travel to go see them. They’ve had people that have died. So, I think that starting off the visit with that, because they also say to me, and how were you and how is your family? So, there is this communication of we’re all in this together and how can I help you to make it better? So, I think that the key thing and I always tell my staff to not tell my patients to address, before I see them, this is something I got from social medicine, I always meet them with their street clothes on, so that we’re at an equal foundation and it’s a conversation. We have a conversation about why they’re there, what my expectations for the visit are and what are their expectations for the visit because they could conflict. I mean, I’m there and I just want to do their exam and get them out or something like that. And they’re there because they have this long-standing pain that they haven’t had anybody listen to them about. I have to adjust well, in addition to doing the things that we need to do for this preventative care visit, let’s get a sonogram, well, let’s find out what’s going on that you have pain or that you have these things going on. So, it’s a give and take the other thing and I suffer from this because what happens is sometimes, I don’t do my notes as I’m seeing them because I would have to then be on the computer, and I feel like I don’t want to be typing when they’re talking to me, so sometimes I use the in-between times to do the medical record or I just take notes and then later on, after hours I’ll do the visit records. But I think that the most important part of any kind of visit is communication and making sure that you find out, not only the physical problems, but what are the worries, are you depressed, or do you have a job, do you have a place to live, or do you have enough money for food? All of the things that we quote/unquote, call the social determinants of health, but that are really part of the day-to-day of our patients.
Dr. Campos: It sounds like you just naturally in your course of taking care of people and because you know them. You incorporate questions to find out a little bit more about the individual and their family and sort of the challenges that they’re facing. And I guess today, we’re starting to pay more and more attention to this and finding a way to actually get at it. Such that some systems are beginning to actually, try to assess the social determinants of health into their medical record and also to tie in with community agencies so that things can be done about certain issues. It’s very difficult though, isn’t it for healthcare systems to really get into that. It almost seems overwhelming in terms of the problems that patients come to you with and how can one person or one even healthcare system deal with them? But do you think it’s worth the try in terms of at least assessing and then taking it from there? This is what we’re finding. What could we do about this? Maybe just this one thing. If housing is an issue, what can we do? What has it been in your experience with that?
Dr. Correa: Absolutely, I think that it’s a hundred percent worth the effort of making sure that this happens. In private practice, it’s harder because you’re isolated and you don’t have a social worker down the hall or somebody who can help you with this. But we do have access, if someone is depressed to making sure they get a referral for counseling or to make sure that they do get referrals and that you fill out forms for them so that they can work with their housing needs or whatever needs they have. I’m so blessed that when I went through social medicine, it was the beginning of the community health system and the building of community health centers, which were manned or staffed by people from the community. And we were lucky to have social workers and lucky to have access to… the main thing that we lacked access to in all of these systems, was specialty care. Because there’s primary care and then when someone needs the experts or the tertiary care providers, it becomes very important for there to be these links, these communications between the primary healthcare system. And again, in Health and Hospitals, we’re lucky because we do have access, you know, if somebody needs bypass surgery, well there is a hospital in the system that they can be referred to, or if somebody has appendicitis and they need an appendectomy, we can get them all that. It’s harder, I think if you’re an isolated practitioner in private practice, or if you’re in a clinic that does not have the ability to provide these kinds of services. So, as I said, I’m lucky because I’ve had access to work in all of these settings and I know the continuum and what a blessing it is to be able to call the social worker on the phone and in a few minutes, she’s able to talk to the patient and spend a half an hour trying to figure out how she can help them with their housing need or their crisis, or if they have a child, there’s violence, or there’s a child that’s having some mental issues. That there are people there that can be supportive of that because I think health is not an isolated thing. You can get all your colonoscopy, your mammogram, everything that you need, but if your heart is broken because your teenager is pregnant, and you don’t know what to do, that kind of stuff. And the other thing I will try to do is go generations, so if they have children, they start asking me, well, when should my daughter go to the gynecologist? I tell them, whenever you think that she has questions that need to be answered, and it doesn’t have to be for an exam. It could just be to prevent the teen pregnancy or to help with whatever’s going on with her at school, is she being bullied, is she happy, those kinds of things. So, you kind of extend beyond the patient, you go to the patient and the family, you go to the patient and the community. Do you feel safe, can you exercise, can you get the right foods? So, social determinants of health is really all about holistic care and making sure that somebody is taking care of in ways that they need to be taken care of. You have your usual patients that have no problems at all and those are the ones that you just believe them, they tell you that they don’t have any problem, don’t look for problems but if they do, you go there.
Dr. Campos: Exactly, so one of the things that strikes me then that what you’ve said is in some ways, small private practices can get at that a little bit easier than big systems. I think that one of the things that we know about value-based payment models is that it has put the squeeze on a lot of small private practices. And I’ve spoken to you before, and you’ve talked about different colleagues of yours whose practices have not survived, not only the models, but the pandemic and are closing their doors. So, it leaves people out without doctors and providers they’ve had for many, many years, who knew all about them and now are forced into either other providers, if they can take them, or they’re forced to hospital ERs when their need arrives. What has been your experience with that, in the Bronx?
Dr. Correa: Sadly, I think that many of the programs that are doing the kind of reimbursement that is leading to value-based payment have left out the private practitioner and the value that the private practitioners have to the community because they happen to be the go-to doctors, the doctors who sometimes speak their language and the ones who are familiar with what their problems are. And I’ve had many colleagues that have either had to close their practices because they were working just to pay their employees and their rent, or they’ve had to sell them or give them to the big hospitals. And what happens is they stay as employees of the hospital during the initial years, and then eventually are replaced by younger doctors who may or may not be familiar with that community and that to me is a sadness because I think that in the reimbursement model, for instance, in New York State, we have several models and one of them is called CMO or an IPA, where Medicaid funds are given to either an institution or a group and then they are to evaluate the quality of care that is being given in the private practice and they decide how much reimbursement or how many incentives their particular practice is able to burn. What happens is, we talked about quality of care, and of course, sometimes people will see a private practitioners practices not having quote/unquote quality, because they haven’t met certain criteria or certain things that need to be done like the eye test or something and then, they’re kind of dinged because they haven’t done those things, but on the other hand, they’ve been available to that patient for the abdominal pain, the sore throat, whatever is going on with them at that particular time. So, in our efforts to try to get standardized care and to have criteria that people follow, cookie cutter criteria, sometimes you miss out on the value that the patients get from the access and the value that the provider gets from the satisfaction of taking care of patients within their community. So, those, too are values, but sometimes they don’t get measured into the equation the way that we would want them to be.
Dr. Campos: I think that’s a great point, you kind of throw out the baby with the bath water sometimes, it’s a subtle thing maybe to some, but it’s real to the patients and to the physician taking care of them. And the system doesn’t really account for everybody, so there’s people that are left out of it, providers and patients and I think that’s something that needs to be corrected for sure.
Dr. Correa: Also, I’m a proponent of evidence-based care, so certainly you want to follow the guidelines and you want to make sure that people get quality and that they get what they need to get. And much of our evidence shows us that things make sense, one of the things we struggle with is the annual Paps, the rules changed. So, I have to spend a long time telling my patients, you don’t need a pap every year, but it doesn’t mean that you don’t need an exam every year. You still need to come, you still need to have, but you have to take the time for education. And they’re still worried, you mean, if I don’t get my Pap every year, I could get cervical cancer. And I have to inform them about the data and reassure them that with the new HPV testing, it’s okay not to have a Pap every year. So, we make deals, let’s do a pap in two years instead of three years and stuff like that because they feel way more comfortable with that. On the other hand, I have some that say, “Oh, good, I’ll see you in three years.” “Don’t do that.” I can’t tell you how many patients I see in two to five years, because now they don’t have to have an annual pap and start all over with them because they haven’t had a mammogram either and they missed the colonoscopy. So, those are the things that we know that preventative care work. I spent a lot of time giving them booklets on diets and diabetes prevention because diabetes is a big problem. So, where can they exercise, do they have a safe place where they can go walking or jogging if they want a jog? How do they begin? Even referral for bariatric surgery, because one of the things that I’ve seen is the obesity epidemic in New York is just horrific. And you have women that weighed 150 pounds and now weigh 300 pounds, and we don’t know where to begin. And sometimes the beginning is bariatric surgery, and they feel so good after they’ve had the surgery and lost those extra 150 pounds.
Dr. Campos: Lost their diabetes.
Dr. Correa: Diabetes and they lose their diabetes, and they lose their hypertension. So, we can have great interventions, we just need the ability to have someone to receive them to do that tertiary care and then get them back.
Dr. Campos: And you bring up a really, good point. Some of the unintended consequences of these models is, what’s called cherry picking/lemon dropping. In other words, if patients going to cause a lot of problems in terms of money and cost, you maybe just don’t take them onto your plan, if you have a choice and you pick the healthier people, and your plan can actually work a little smoother. Sounds like the systems that you’re involved in though, there’s no lemon dropping/cherry picking, you just take all comers, in both the hospital and in your private practice, you’re not making those kinds of decisions.
Dr. Correa: We leave that up to them to reject us.
Dr. Campos: And it’s actually heartening to know that there are providers out there who don’t do that, who take all comers. And I think I was discussing with someone yesterday, somebody says, “Oh, well, everybody takes Medicare.” I said, “No, they don’t. No, they don’t.” Medicare is not taken by every single provider, unfortunately, and Medicaid certainly is not.
Dr. Correa: People are trading in their Medicare for HMO Medicare, that’s when they run into problems. Because the HMO Medicare promises them the world, dental, eyes, the world and then when they go to their provider, they say, “Oh, no, we don’t take this one.”
Dr. Campos: Right and that’s the problem, that’s the Catch 22, isn’t it?
Dr. Correa: Right.
Dr. Campos: You have it, but there are subspecialty providers that do not take it.
Dr. Correa: The same way the Medicare card used to be carte blanche, you do have to pay your 20%, however, you can go anywhere with that Medicare, but once you trade it in for whatever specialized Medicare programs are out there, you’re at the risk of losing your steady providers and having to start all over again.
Dr. Correa: Well, I can almost tell how you’re going to answer this, but I’m going to ask you anyway, and that is your own personal definition of value in healthcare. What do you think value is? We looked at what the payers think it is, performance measures, all sorts of things, bundled payments. How do we get the most efficient and the most cost-effective medicine for our dollar and that’s really what they’re thinking about it? There’s involvement of quality, but quality for them is something that can be measured and that requires the provider to actually, put the resources into their clinics and practices to measure and to report out. And we talked a little bit about the hospitals themselves and individual providers. And so, I’d like to have you tell us what you think as a private doctor, what is value to you?
Dr. Correa: Well, I think to me, as a practitioner, as a provider, value is, first of all, having the time and the ability to communicate with people when they come to me for services and to be able to meet them where they are and begin to help them to wade through. I think that people need to be empowered and to have the ability to decline certain things that they don’t want to do and also to be able to communicate what it is that they need. So, to me, value is being able to provide for people where they are depending on what their needs are. And communication, I think is the key to that, because if I let them talk a little, and if I listen, then I will be able to give some value, that they perceive as value for their visit. So, to me, communication is the most important thing. And then, I think being respected. Often, now, with all of the changes and with the focus on administration and this quote/unquote value-based evaluation, they don’t see the value in that human part of it and the amount of training and the amount of experience that one brings to being a doctor and to providing these services. We’re not widgets. We can’t work in 10-minute slots or 15-minute slots, some visits will take a half an hour and another one will take five minutes. But to me, I like to work within a system that values me as somebody who can take care of whatever needs to be taken care of, or refer, not ignore things that need to be taken care of. So, I think that value is a double-edged sword and sometimes we get it, but the most important thing is to be able to communicate. And especially for somebody who’s having a visit and they’re not happy with what happened that they’re able to say, no, this is not what I came for. And as they have their hand on the doorknob, they tell you, “Oh, I have this lump on my breast,” and your heart sinks because, you know you’ve missed the boat.
Dr. Campos: Boy, I remember that. So, if you had Joe Biden’s ear about healthcare and how to make it better, what would be your ideal healthcare system? What would you tell President Biden’s administration about how you’d like to really see health care go?
Dr. Campos: First of all, I think that I would advise him to continue with his gentle, thoughtful evaluation of things and to move in those directions. But to me value means access for everybody and access to me does not mean insurance, it means real access. So, I would be a proponent of universal healthcare so that everybody could have a baseline health policy. And then, if someone had additional money to put into extra services, that they would be able to purchase that. But the healthcare to me is a human right and that access to healthcare and a system that takes care of everybody on an equal basis, regardless of whether they can pay or not, regardless of their race, color, immigration status, economic status. I’m a dreamer, but I think that we can get there and a lot of times if we really think big, we can figure out how we can take out so many middlemen and middle that benefit from the healthcare system. And not have a lot of insurance agencies pay their stockholders most of the money, and then try to limit access to the technology that other people are entitled to, if they need it. So, my mind would be a very equitable kind of utopia.
Dr. Campos: Well said, I think that you’ve, you’ve hit you’ve hit something that Movement Is Life is very, very concerned about and working hard towards the equity in healthcare. And it’s really been wonderful speaking to you because I feel that you, despite the challenges and you certainly let us know how those go and it doesn’t sound easy and certainly we know how difficult it has been for many of the patients out there, it’s not easy for them either, in getting left out of the system. But you’ve also given us a view of a person who actually really tries to do the best they can within the system given and is optimistic about it going in the right direction. And I think that’s really, really wonderful to hear. So, Dr. Correa, thank you so, so much, it’s been wonderful speaking to you, and I hope to have you back again sometime.
Dr. Correa: Thank you and thank you for listening to my rambling, and it’s been an honor and a pleasure.
Dr. Campos: Oh, no, no, not at all. And giving us just a really wonderful glimpse of the changes taking place at the primary care level from your perspective, and I think it’s been so valuable. And I, also, want to thank all of our listeners for joining us today, you can access a transcript of the podcast and all of our previous podcasts on our website movementislifecaucus.com. (Rolf: I’m sorry, could you read, movementislifecaucus.com? Dr. Campos: Oh, thank you for saying that because I didn’t write it down that way. Okay. Dr. Correa: Now, you’ve got to start all over again. Dr. Campos: Where do I have to start?) I also want to thank all of our listeners for joining us today. You can access a transcript of the podcast and all of our previous podcasts, on our website, movementislifecaucus.com and remember to subscribe to our Health Disparities Podcast on iTunes, Spotify, Stitcher, Google, or Apple podcasts. Our monograph, “Values Defined by Whom?” Can be found on the website, start movingstartliving.com, go to resources and you will find the link to the monograph under booklets. Please be safe, be well and keep working for health equity. So, until next time, goodbye for now.
(End of recording)
download pdf transcription of this episode
