Sunday, April 14, 2019

Step Therapy - Pharmacy Benefit Managers are at it again!


Among the many tools that insurance companies wield to save money is a technique called ‘step therapy’.  This is a technique that exasperates patients and physicians.  Here’s how it works. 
A patients comes to his doctor with a medical issue.  The doctor, who presumably has a decent measure of medical training, experience and judgment, decides to prescribe a medication, in an effort to ameliorate the patient’s distress.  Let us call this magic elixir Pill A.  The doctor zaps this prescription to the pharmacy at the speed of light using the ever trustworthy electronic medical record.  The satisfied patient leaves with the mistaken impression that his cure is just around the corner.

Here’s where the fun begins.  Of course, the patient may receive the typical denial as Pill A is not on the formulary.  Keep in mind that an insurance company’s denial doesn’t mean the patient can’t fill the prescription.  Insurance companies would never interfere with a physician’s medical judgment.  The patient is still free to take the prescribed drug.  The fact that it costs $2,200 per month is but a trifle.   If Pill A costs a fortune and the insurance company’s alternative Pill B is cheap, then can we really argue that insurance companies are not practicing medicine?

Physicians in Asylum Driven Mad by Step Therapy

In the above example, usually Pill A and Pill B are medically equivalent, so the cheaper drug delivers the same benefit.  Sometimes, however, the doctor’s preference is medically superior.  Either way, the process burns up hundreds of hours per year for physicians and our staffs. 

Step therapy is when Pill A is denied because the doctor has not tried different types of medication first, which are not equivalent and are often inferior.  In order to get Pill A to be covered, the doctor must demonstrate that he has tried other medications first, and that they were not effective.  So, under this genius system, a patient receives drugs that cost money and likely won’t work.  After enduring this experiment, the  insurance company may ultimately cover the medicine that should have been prescribed in the first place.  Usually such approval is for a limited time guaranteeing that the physician can look forward to a sequel in the near term.  

Imagine if a patient suffered a serious side-effect from one of the step therapy drugs that the doctor knew was a waste of time.

I’ve argued on this blog on the need to reduce overutilization and to cut costs.  A fundamental premise of this blog is that less medical care can increase medical quality.  Step therapy managed to both increase costs while it cuts quality, not an easy feat.

We need to step up and step on step therapy.

Sunday, April 7, 2019

Why I Fired Two Patients From My Practice



You're fired!  We've all heard this directive that was popularized by our current chief executive.

It is much more common for a patient to fire a physician than it is for a doctor to cut a patient loose.  Yet, I sent 2 of my patients termination letters in the month prior to my penning this post, which represents a firing surge on my part.  This has been a very rare event in my practice.  Since physicians are patient advocates by training and practice, we tend to extend leniencies to our patients, giving out 2nd and 3rd chances routinely.  But, the doctor-patient relationship is not unbreakable and both sides have responsibilities to maintain it. 



The Doctor-Patient Relationship Should be a Partnership - not a Duel.

Here are some reasons that patients have offered justifying seeking a new physician.  Keep in mind that these given reasons represent patients’ perceptions, which may not necessarily represent absolute truth.
  • Poor or absent communication.
  • Inattentive or rude staff.
  • Unreturned phone calls.
  • Habitual physician tardiness.
  • Diagnostic delay or error.
  • Dismissive attitude toward chronic medical complaints.
  • Insurance coverage change - not a true 'firing' but a common reason to change horses.
  • Suggestion that patient’s complaints stem from anxiety or depression.
  • Refusal to order requested diagnostic testing.
  • Rushed office visits.
  • Arrogance toward complimentary and alternative medicine. 
  • Unavailable timely appointments. 
Here’s why I sent two patient pink slips.

Patient 1:  I saw the patient in the office and scheduled her for diagnostic tests at our local community hospital.  This appointment time requires a commitment from me, the endoscopy department and the anesthesia personnel to be available at the appointed hour.  After the patient cancelled for the 3rd time, we declared ‘no mas’.

Patient 2:  He is on a medication for colitis that suppresses the immune system.  This requires that he periodically check in with me for office visits and laboratory studies.  He missed his appointment and was due for his blood tests.  We called and wrote reminding him that I needed to see him.  He declined.  I wrote him a personal letter requesting that he make an appointment or I that would need to sever him from the practice.  When we didn’t hear from him, we followed through.  

It’s challenging enough to take care of sick patients who are playing by the rules.  When a patient decides to make his own rules, and can’t be coaxed back into reasonable compliance, then the doctor-patient relationship may traverse the point of no return. 

When a patient fires a doctor or a physician dismisses a patient, there is an opportunity for reflection and growth.  Just like in the business world, a person who is fired should want to know why the action was taken so that he can learn from the experience, rather than simply blame the boss.  Conversely, an experienced manager will want to understand why an employee has given notice.   

On those occasions when a patient has left my practice, I have tried to understand if I or we fell short.  Sometimes we have and we do our best to learn from the experience. 


Sunday, March 31, 2019

The Mystery of Medical Insurance Coverage


“Does my insurance cover this?”

I cannot calculate how often a patient poses this inquiry to me assuming wrongly that I have expertise in the insurance and reimbursement aspects of medicine.  If I – a gastroenterologist –  do not even know how much a colonoscopy costs, it is unlikely that I can speak with authority to a patient’s general insurance coverage issues.

Of course, patients assume that we physicians have an expansive expertise of the medical universe, both in the business and the practice of medicine.  Often, friends and acquaintances will informally present a medical issue for my consideration that is wildly beyond my limited specialty knowledge, and yet they expect an informed opinion.  “Hey, aren’t you a doctor?”   Yes I am, but if you think a gastroenterologist – a Colonoscopy crusader – can advise you on your upcoming hip surgery, psoriasis treatment retinal detachment, or cardiac rehab, think again. 

And, I likely know more about psoriasis treatment than I do about the enigma of insurance coverage.  I have to check with our billing expert to understand my own medical coverage and I’m in the business.  And, at the risk of appearing as a simpleton to my erudite readers, I cannot aver that I fully grasp the meaning of the E.O B. (Explanation of Benefits) forms that I receive for my own care that purport to explain exactly where my insurance company responsibilities end and mine begin.

Imagine for a moment that you are an actual physician as you counsel a patient who is sent to you for a screening colonoscopy.  (To assist you in this role play, a screening colonoscopy means there are no symptoms or any other abnormalities that would justify the procedure.  A screening study is done on patients who are entirely well as a preventive medicine exercise.  In contrast, if a patient has a symptom, such as pain or bleeding, then the colonoscopy is considered diagnostic and not screening.) You advise your 50-year-old patient that his screening colonoscopy will be fully covered by insurance. The patient is happy.  However, during the screening colonoscopy, a polyp is discovered and removed.  Indeed, removing polyps is the mission of the procedure.  However, polyp removal automatically changes the procedure from screening to diagnostic.  And, guess what?  Now, the procedure may not be free and the patient may be subject to copays or diving into his deductible.  When the patient receives his E.O.B, and properly decodes it, he is no longer happy.  Then, our office is likely to receive a phone call.


Can Sherlock Holmes Deduce the Cost of Colonoscopy?


This is but one example of the Medical Insurance Industrial Complex.  Even our most seasoned patients are no match against this machine.   It’s not a fair fight.  They make the rules, change them at will and serve as the referees.  And, if the insurance company ruling doesn’t fall your way, relax, you can certainly appeal. This process is about as pleasurable as undergoing a rigid sigmoidoscopy.  The appeals process is not for the faint of heart.  You must have the patience of Job, the fortitude of a Navy SEAL, accept rejection gracefully, welcome irrationality, regard a dropped phone connection as an amusing event and have several consecutive hours available typically at times most inconvenient for you.  On reflection, perhaps the sigmoidoscopy is the more pleasant option. 


Sunday, March 17, 2019

Why Our Medical Practice Won't See Nursing Home Patients

Our practice will no longer see nursing home patients in our office.  If a nursing home patient is already established with us, then we will see him; but, we have decided not to accept new patients.

Of course, we believe that these individuals – like the rest of us – deserve medical care.  This demographic not only deserves care, but has the greatest need for medical services.  Our practice will see every person who wants to see us, including the uninsured. 

Why, then, would a welcoming practice like ours close our door to new nursing home patients?  We just couldn’t take it anymore.

These patients, who often have serious physical and mental challenges, would typically arrive to our office accompanied by a driver, who naturally has no medical knowledge.  The patient often had no awareness of the reason for the visit.  The ‘medical record’ consisted of a nearly indecipherable list of medications of uncertain accuracy.  Typically, no reason for the visit was documented, or there might appear a scrawl - ‘stomach problems’ - not quite a road map that a consulting gastroenterologist can follow.  I would then, in the middle of my practice day, call the nursing home in search of a nurse (or nurse’s aide or secretary or janitor) who might enlighten me on what my focus should be. This task is about as fun and efficient as calling the IRS customer service line with a tax question.  Often, the nurse who might actually know the reason for the visit is off that day or works a different shift.



Why Should We Have to Work Wearing a Blindfold?


It took several years before our practice declared ‘no mas’, but our level of exasperation finally exceeded our patience.  Our repeated attempts to improve communications  were not successful. 

Here’s what didn’t happen.
  • The patient’s doctor or nurse would call us in advance to discuss the case so that we might gain information that would make an office visit worthwhile. 
  • We are contacted in advance and we advise that a diagnostic test or blood tests be performed prior to the office visit.
  • We are contacted in advance and, after discussing the case, request certain prior medical records to be sent prior to an office consultation.   If a patient is having rectal bleeding, for example, I want to review the prior colonoscopy records.  Perhaps, a repeat procedure is not necessary.  
  • A family member accompanies the patient to the office visit.  I am not judging folks here, and family members may live out of town, but I was always surprised that these ailing and elderly patients rarely arrive with a family member who could play a critical role of providing (or obtaining) medical knowledge and advocating for their loved one. 
This has been a vexing issue.  If you were sending an elderly patient, perhaps demented, to a doctor, why wouldn’t you give that physician a full briefing so that he or she could do a decent job?  Even when we are sufficiently informed, the task is challenging.  But, we shouldn’t be asked to work blindfolded in the dark.

Sunday, March 10, 2019

Quality Indicators in Colonoscopy - A Three-pronged Test for your Gastroenterologist


One thing that gastroenterologists know about is stool.  But, I’m not referring to that kind of stool in this post.  Follow along.

When we do a colonoscopy, for example, we are relying upon stool, or more accurately a stool, as in a three-legged stool.   This metaphor illustrates that the three legs must be equally strong or the stool will not stand.  The three pillars of support that a colonoscopist needs include:
  • Knowledge
  • Skill
  • Judgment

All 3 Legs Needed


As the gastroenterologist guides the colonoscope along your long and winding colon, he may discover a lesion.   He needs knowledge to identify the intruder.  Is it a cancer or a benign polyp?  Could it be Crohn’s disease or some other form of colitis?  Is it a normal structure that simply appears atypical? Obviously, the more experienced the gastroenterologist is, the more likely he will be able to identify the abnormality. But, every gastroenterologist, regardless of experience, confronts lesions he has not seen before. 

The gastro specialist must have the requisite technical skill, not only to perform the colonoscopy properly, but also to manage any lesions discovered.  Removing colon abnormalities requires an assortment of techniques and instruments.  What good is having the knowledge that can identify a lesion if you don’t have the skill to remove it?  Would we permit a cardiologist to perform a cardiac catheterization on us if he couldn’t insert a stent if a narrowed artery was discovered?

Most importantly, the gastroenterologist needs judgment.  In my view, this ‘leg of the stool’ is what distinguishes good physicians from truly seasoned medical professionals.  Medical judgment, in my judgement, is much more difficult to learn that knowledge or skill.  By definition, judgment is subjective.  There is no medical bible to consult that can confidently advise what constitutes the optimal judgment in a particular circumstance.  There are so many variables.  This is why a patient could consult several specialists regarding a medical issue and receive differing opinions all of which might be ‘correct’.  The facts don’t change, but the physicians’ interpretations of those facts and consideration of the overall medical context, may lead to opposing recommendations.  One physician might advise repair of a hernia which is causing discomfort while another may counsel against it because the patient has severe emphysema and has high operative risks. 

Consider how many U.S. Supreme Court decisions are decided in 5 to 4 votes.  The facts are the same for all 9 justices but their decisions often vary profoundly.

Two hours before writing this, I performed a colonoscopy.  I discovered a medium sided polyp right at very end of the colon at the spot where the appendix is connected.  I had knowledge of the lesion and had the skill to remove it.  But, I was concerned that resecting it – a simple task I’ve done for decades – might cause a complication by injuring or puncturing the appendix.  Primum non nocere, or first, do no harm, is medicine’s sacred mantra.  Perhaps, another gastroenterologist would have removed the lesion without any consequence.  His patient would not need any surgery to remove the lesion, as my patient might.   The patient will return to my office in a few weeks.  I thought that he was entitled to a sober discussion of the options while he was awake and alert, rather than sedated on a gurney. 

Sunday, March 3, 2019

Medical Practice Hassles Torture Patients and Doctors

We do most of our colonoscopies in our ambulatory surgery center (ASC), which is attached to our office.  We are proud of the work that we and our staff do every day and are grateful for the outstanding feedback that we consistently receive from our patients.  Some insurance companies will not cover procedures in our ASC so these patients must get ‘scoped’ at the hospital instead.  For many of them, this means required blood tests a few days in advance of the procedure, which we would not have required for an ASC procedure.   On the procedure day, the patient and the driver will enjoy spending hours in the hospital for parking, checking in, interviews with various medical personnel, the procedure and the recovery period.  And, since it is a hospital, delays are inevitable.  Not only does this experience take hours longer than it should, but we are mystified that an insurance company would take on the expense for a hospital test that we could do more efficiently and cheaper in our ASC.  Can you make sense out of this?

It is typical for a physician’s prescription for a patient to be ‘denied’ by an insurance company.  Such denials, of course, are never issued by a medical professional, but are form letters kicked out automatically if the physician’s preferred drug is not included in the insurance company’s sacred formulary.  Appealing a denial – which we will attempt – is just as smooth and stressless as calling the IRS for questions on your tax return.  It is designed this way so that physicians and patients simply give up.  What physician has the time or fortitude to make several phone calls to hear repeatedly, ‘please listen carefully as our options have changed…”  Sometimes, my recommended drug is denied because my patient has not first tried a different medication, which I did not prescribe because it is not indicated for my patient’s condition.  Should I prescribe the wrong drug so that few weeks later when it is not effective, I can then hope that the correct medicine will be approved?  Can you make sense out of this?



The System Can Make Doctors and Patients Batty


Some insurance companies will only permit me to prescribe a 30 day supply of a medication.  Some of these medicines need to be taken indefinitely.  Why should these patients have to make 12 stops to the pharmacy every year?  Why can’t I prescribe a 3 or 6 month supply?  Can you make sense out of this?

A patient comes to me for a screening colonoscopy.  His insurance company covers this preventive service.  I do the exam and find a polyp, which I remove.  This changes the definition of the procedure from screening to diagnostic.  Why does this matter?  Because the insurance company may require that the patient pay a greater share for a ‘diagnostic’ procedure?  In other words, the patient gets penalized because his gastroenterologist removed a polyp, which is the goal of a screening colonoscopy.  Can you make sense out of this?


If any reader can make any sense out of these real life medical absurdities, then the medical profession needs you STAT.  You are much smarter than we are.