Sunday, October 2, 2022

Why Isn't My Drug Covered by my Insurance Company?

Over recent weeks, several times I have prescribed medications for patient that they could not afford.

Insurance plans do not cover every benefit.  With respect to drug coverage, each insurance plans has a formulary - a listing of drugs that are covered.    As patients have learned well, covered medicines are categorized into different tiers, which determines to what extent the medication will be covered  The lower the tier number, the more money that the patient will have to surrender.  Some drugs are simply not on the formulary and can have eye-popping costs which might approach a patient’s monthly mortgage payment.


Distraught woman hoping for a win so she can afford her colitis medicine.


The two medicines that I had prescribed which were then stiff-armed for coverage were for colitis.  I had the patients research the costs and they and I were shocked by their findings.  At first, I thought they may have misplaced the decimal point, but the more expensive of the two was priced at $2,000 for a prescription.

Sparing my readers the medical details, both of these medicines are considered mainstream colitis medicines.  They have been approved for this use by the Food and Drug Administration (FDA) years ago.  And importantly, neither has an equivalent alternative.  For example, if I prescribe a heartburn medicine and discover it is ‘off formulary’, there will (hopefully) be equivalent alternatives available for the patient.  Not so with my recent colitis patients.

How would it feel to be sick, have medical insurance and not be able to afford the medicine that would make you well?

For luckier colitis patients whose medical plans cover these drugs, the costs are extremely low.  What this means to me is that the system is unfair and broken.

Leaving aside contracts and formularies and the overall labyrinthine insurance companies, shouldn’t a patient who has insurance and who’s played by all the rules be covered for an FDA approved medicine that his doctor recommends? 

Sunday, September 25, 2022

Should I Fire My Doctor?

A day prior to this writing, a man well into his eighth decade came to see me for the first time.  He wanted advice from a gastroenterologist.  So far, this quotidian event is hardly newsworthy.   I asked him, as I ask every patient, if he had ever consulted with a gastroenterologist (GI) previously.  For me, this is a critical inquiry as it often opens a pathway to a reservoir of information.  For instance, if the patient responds that he saw a GI specialist 3 months ago for the same symptoms, but no cause was determined even after extensive testing, then I know that obtaining these records will be critical.

Or, if a patient tells me that he loved his prior GI specialist, but he has to see me because his insurance has changed, then I know that I have be particularly mindful to establish good rapport.
Sometimes, patients change physicians or specialists because they are dissatisfied.  Patients uncommonly volunteer the reason, but I ask them directly why they have sought to make a change.  This is not simply to satisfy my curiosity; it can yield very useful information.   Read through the following sample explanations of why patients have left their gastroenterologists.  I think it will be readily apparent why this information would be very useful to the new physician
  • I need a new GI.  My former gastro doc wouldn’t give me any more pain medicine.
  • All he did was do one test after another.  I think he was in it for the money.
  • She thought the pain was in my head and I know I’m not crazy.
  • He was more interested in the computer than he was in me.
  • He just didn't seem to care about me.
  • She messed up and totally missed my appendicitis!

For my new patient, it was a matter or time.

I am not suggesting, and readers should not infer, that the above reasons are all factually correct.  They are perceptions and it is likely that the prior gastroenterologists would offer different narratives.   My task is not to establish the truth.  The patients stated reasons for abandoning a prior physician help me to understand them better and adjust my approach. 

The septuagenarian who was now before me left his GI physician whom he had been seeing for nearly 30 years. This physician was always running behind and the patient routinely waited an hour for  his appointment.  This increasingly irritated him and persisted even after he voiced his annoyance to the doctor.  I can’t explain why he waited decades to act, but everyone has a breaking point.  So, now he’s mine.  And, you can bet I’ll do my best to see him on time.  


Sunday, September 18, 2022

Doctors Performing Unnecessary Medical Procedures

If a patient wants a colonoscopy done, and it’s not medically indicated, should the doctor still do it?

If the physician complies with this request, has he or she committed an ethical breach?  Should the medical board or some other disciplinary agency be notified to investigate?

Of course, in a perfect world every medical procedure or prescription would be advised only if it is medically indicated.  But the world is not perfect and there are instances when good physicians may deviate from established medical dogma.


Doctors Performing Unnecessary Medical Procedures

We Inhabit an Imperfect World

Consider these examples and whether you think that a disciplinary response is appropriate.

  • A patient is due for his next screening colonoscopy in 2 years, which would be 10 years since his last exam.  He approaches his doctor with anxiety because his coworker was just diagnosed with colon cancer.  He asks that a colonoscopy be scheduled now.  The doctor agrees.
  • A patient wants his colonoscopy performed in December, after his deductible has been satisfied, rather than wait until July of the following year when he is officially due for his next exam.  The physician accedes to this request.
  • A referring patient requests that his patient undergoes a screening colonoscopy earlier than advised because he feels that the published guidelines from screening are too lenient.  The gastroenterologist complies.
  • A frail, elderly patient has some modest bowel concerns.  The gastroenterologist does not suspect that these symptoms portend a serious issue.  The patient is accompanied by her two children who are firm in their desire that their mother undergoes a colonoscopy to assure that all is well.  The patient grudgingly agrees to proceed.  The doctor schedules the procedure.

So, should these ‘rogue doctors’ be reined in and disciplined?  Or are these simply examples of imperfect practitioners functioning in an imperfect world trying to satisfy imperfect patients?  Do you agree that strict medical criteria should not be the sole criteria that physicians use?

 

Sunday, September 11, 2022

What are the 10 Most Important Things in Life?

Our favorite restaurant has closed.

A child’s toy is left behind on a trip.

Our dog ran away.

We have all observed that the value of something in our lives becomes well known to us when it is missing.  The loss of a job, a friendship, financial security or one’s health are cold reminders of the worth of these items in our lives.  How important are the people in our lives?  We’ve all been taught this lesson the hard way.  Of course, it is human nature to take one’s advantages and blessings for granted.  I do my best to pause from time to time to meditate on the gifts that have fallen my way, many of which are undeserved.  I certainly need to do this more often. In fact, I don’t think one can do this often enough.



Do Flowers Really Matter?


I think most of us would agree that life is richer when we appreciate what we have while we still have it.  In the course of a long medical career, I have met so many inspiring individuals – happy and content with their lot in life.  They are grateful for what they can do which may be different from what they were able to do in the past. These are special people.  They seem to know what really matters and prioritize  accordingly.  They are great role models.  For those of us who take too much for granted, we routinely allow items of lesser value to ascend higher than deserved on the priority ladder.  I certainly struggle with this issue.  The first step in this challenge, I think, is to give life to this struggle and to engage in it.

Think of the 10 items in your life that you value most.  (Not 10 items that sound like the right answers but the 10 items and activities that truly command most of your time and attention.)  Are you satisfied with your list?   Are your top list entries deserving of this status?  What has been devalued and left off the list?  Does performing this simple list-making exercise seem like worthwhile endeavor or is it more like a banal classroom exercise that would only burn up your time?  Or, is it worthwhile just to check in with yourself from time to time?

Somewhere on my own list (can't say for sure if it's top 10 material)  is the joy and satisfaction I receive from writing this blog, still in full force since 2009. It gives me the opportunity to think, craft an argument, assess an opposing viewpoint and put it out in the public square.  I've often criticized the government and others, activities that could land a blogger in jail in many parts of the world. And when readers engage on a post, especially when they disagree with me, it fulfills the blog’s purpose.  I hope that this is a place where readers and myself can be open to other points of views and might even engage in a rare event these days. Changing one's mind.

Sunday, September 4, 2022

Labor Day 2022

Labor Day became a federal holiday in 1894, during the presidency of the only chief executive who served two non-consecutive terms. (Have I tempted you to look up this piece of presidential trivia?)  This holiday emerged from an overheating crucible containing worker exploitation and worker unrest. All of this let to labor reform.  Change so often requires disruption, discomfort, protest and even violence.  Clearly, the antebellum conflict between the northern and southern states, for example, was not to be resolved peacefully.



He served 2 non-consecutive terms.

There are still, of course, unfair labor practices and worker exploitation.  Are Uber drivers employees or independent contractors?  Did Starbucks retaliate against employees who wanted to organize?   But to be fair, we must acknowledge that great progress has been made that is still ongoing.  Oftentimes, when a particular struggle has not yet achieved its full mission, folks point out the distance remaining rather than the distance traveled.  Acknowledging progress should be readily and enthusiastically expressed even if the destination has not yet been reached.  'But we still have a long way to go' is often give as a default statement.  And for many of these struggles, complete success is aspirational.

Labor Day honors the working men and women of this country, those who do the blocking and tackling to keep this nation moving downfield.  Without their contributions, this nation would be but a shell and a shadow of what we are today.  I salute you all. 

Sunday, August 28, 2022

Why Won't My Doctor Refill My Prescription?

Medical care has various tiers of service with differential quality levels.   Each level is designed to meet a specific level of need.  Physicians and patients do not always agree on what level of service is appropriate.  Sometimes a patient feels that a higher level of service is necessary and other times the physician has a similar view.  Consider the listing below of potential medical encounters. 

  • Physician and patient dialogue through the Electronic Medical Record (EMR) portal
  • Physician and patient phone call to discuss a medical issue.
  • Telemedicine visit with audiovisual capability.
  • Traditional office visit with a physician or medical professional.
  • Emergency Room (ER) Visit.

Each one of the above encounters has value, but clearly they are not equal experiences.  The objective is to match the level of the encounter with the medical need.  For example, if you are uncertain if your recently prescribed erythromycin should be taken with food, then an ER visit would seem a step or two too far.  Conversely, if you have developed fever, vomiting and abdominal pain, and haven’t seen your doctor in a year, then leaving your physician a voice mail message seems like a misfire.  

What is the best way to communicate with your doctor?

It's important to know the best way to communicate with your doctor.

I have found that patients tend to inappropriately use lower tier encounters when seeking medical advice. Over the years, thousands of patients have phoned me or 'portaled' me with medical issues that clearly needed face-to-face visits.  These patients often felt that their request for antibiotics or a CAT scan could be easily handled on a phone call.  In general, I ask these patients to see me (or another physician) in the office for a fuller airing of the issues.  After these visits, patients readily appreciate that this higher level of service was essential, particularly when my advice differs from their original request. These patients were utilizing a lower quality platform for convenience which would have been at the expense of quality.  

As always, there are exceptions to everything. Medical judgment is required on how intense the medical encounter level needs to be.  Different physicians have different views and practices on this. Some doctors are more comfortable handling issues over than phone than others.  

Phone medicine can be murky terrain for physicians.  For instance, if you call a doctor after hours who does not know you complaining of chest pain, do you really expect him to simply refill your heartburn medicine?  .