Stanley Feld M.D.,FACP, MACE
Practicing physicians’ frustrations with the healthcare systems are mounting. It is clear that patients are not first. The secondary stakeholders such as the healthcare insurance industry, pharmaceutical companies, hospital systems and the government come before patients in the healthcare system. Money is first for these stakeholders.
The government tries to control its cost as it outsources most of its administrative services to the healthcare insurance industry.
The healthcare insurance industry, pharmaceutical companies and hospital systems try to maximize their profits by trying to get around many of the government’s complex regulations.
The result of maximizing profit is abusing patients’ ability to get medical care and physicians’ attempts to deliver medical care.
Traditional healthcare insurance is not the only way of paying for patient care. It is the most expensive way. Traditional healthcare insurance is most prone to political and moral corruption.
Moral and political corruption leads to increased insurance processing costs which lead to higher premiums and higher deductibles. This leads to less health insurance coverage.
Recently, I wrote about physicians being pawns in the healthcare system. They are the easiest to attack because they are the least organized.
Physicians are the easiest to abuse by the secondary stakeholders because they believe patients come first. Physicians are too busy taking care of their patients to figure out how to respond.
A reader sent me an article that appeared in the Dallas Morning News illustrating a tiny fraction of the abuse physicians take and the lack of respect they encounter when their orders interfere with the healthcare industry’s profit.
The article is about the need for prior authorization to reduce drug costs in an insured patient. As you read this, think of the increase in the insurance company’s administrative waste, and the disrespect for the physician’s time and judgment.
Millions of prior authorization letters are sent every day for drugs, hospitalizations, and treatment plans. They are the result of actions that do not fit into a healthcare insurance company’s computer algorithm.
Insurance company workers know little about medical care these prior authorizations are challenging. These workers know little about medical judgment or medical care.
The healthcare insurance industry believes it is an effective way to prod physicians away from more expensive treatments and toward less expensive alternatives.
It makes it harder to prescribe costlier medications. In reality, it is a wasteful administrative nightmare.
The letter in my hand concerned one of my patients, Mr. V., who suffers from stubborn hypertension. His chart is a veritable tome, documenting the years of effort it took to find the combination of four different blood-pressure medications that controls his hypertension without upsetting his diabetes, kidney disease and valvular heart disease or making his life miserable from side effects. We’ve been on stable ground for a few years now, a state neither of us takes for granted.
But Mr. V. had changed insurance companies, and now one of his medications required a prior authorization. The last thing I wanted was for him to be turned away at his pharmacy and have his blood pressure spiral out of control, so I called right away to sort things out.
Twenty minutes of phone tree later, I discovered that the problem was that I had exceeded a pill limit for one of his medications. Mr. V. needed to take 90 of those pills each month for the high dosage that his blood pressure required. I patiently explained this to the customer care representative.
Equally patiently, she told me that 45 pills a month was the maximum allowed for this particular medication.
Three more phone trees and three more customer care representatives later, my patience was flagging. Apparently a request for 90 pills was flummoxing the system. Representative No. 4 went down her checklist. “Would taking 45 pills per month instead of 90 pills adversely affect Mr. V.’s health?” she asked.
At first I thought she was joking. “Well,” I replied, “it would probably make his blood pressure shoot up in the second half of the month.”
She paused, then asked her next question with the encouraging uplift of suggestion. “Has Mr. V. ever tried 45 pills per month instead of 90 pills?”
Then I realized that she was not joking. “Are you out of your mind?” I hollered into the phone. “It’s taken years — years! — to find the right combination of meds to control his blood pressure without killing his kidneys or making him dizzy or nauseated or depressed or ruining his libido or running his potassium off the charts or breaking his bank account. Do you really think I’m going to randomly jiggle the dosages just for the hell of it?”
“A simple yes or no will suffice, doctor.”
This interaction demonstrates a lack of respect for the physician and his judgment, and a lack of understanding of the patient’s illness. I have said over and over again that you cannot commoditize patients’ illnesses or physicians’ skills.
If the insurance company’s computer system has a beef with physicians’ judgment it should get a second opinion by a neutral expert physician in the field of hypertension to review the chart and the patient’s illness.
The writer says,
“ I bit my tongue for the remainder of my conversation with the insurance company, holding back long enough to obtain the prior authorization that would allow Mr. V. the 90 pills he needed each month. I tried not to break the phone when I finally slammed down the receiver.”
These interactions are not good for physicians’ health or morale.
They increase physicians’ cynicism.
“I’m all for controlling medical costs and trying to apply rational rules to our use of expensive medications and procedures. But in the current system, everything seems to be in service of the corporate side of medicine, not the patient. The clinical rationale and the actual patient — not to mention the doctors and nurses involved in the care — are at best secondary concerns.
In the end, we were able to keep Mr. V.’s blood pressure under control. My blood pressure, however, was a different story.”
These interactions go on daily and waste physicians’ time and energy. Physicians have no ability or representatives to fight back. However, they are ready to fight back. All they need is someone to come up with a plan.
A good start is changing the paradigm of healthcare insurance so that it is a consumer driven healthcare system with consumers being in charge of their healthcare dollars and their health.
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone. Please have a friend subscribe