Tuesday, August 15, 2006

More on my mind...

It has been a long time since I posted but there has been a lot on my mind lately. There have been some issues that have come up that will impact my practice in some way down the future. Some are good, some are bad. There have also been some really absurd things that have come my way lately, most of it makes me wonder about the state of things in the medical world.

Firstly, there was an instance where a patient needed a prescription for generic Wellbutrin for depression. According to my Epocrates, which I use quite often for insurance formularies, it was considered a preferred medication on her insurance plan. However, I got a call from the pharmacy that they needed a prior authorization. Confused, I called this pharmacy benefit manager for her insurance (which had apparently changed without any notification). While I was waiting for 10-15 minutes on the line to talk to a person, the message mentioned that there was a website that they said that I could use to do prior authorizations online. So, I fired up my web browser while I was on the line hoping to see what the situation was. Of course, the website then tells you to do prior authorizations, you can send a letter or by telephone (not online!). Then, their formulary was not up to date because they still state that the medication was preferred. Finally, I did get to speak with someone who had made it a point that he had to create 2 separate cases because I had to request a medication that needs prior authorization as well as a quantity limit override. Then he transferred me to a pharmacist who apparently is the one who determines whether to accept my request or not. The question I recieved was, "Is the Wellbutrin being used for smoking cessation?" My answer was no. My next followup answer was, "Why does it even matter?" I know that health insurance companies are clamping down on expensive drugs and so on but Wellbutrin came as a generic which is actually cheaper than most SSRIs and other drugs that are not generic yet. Secondly, I know that there is product called Zyban that is basically a rebadged version of Wellbutrin but much more expensive (like as if a doctor couldn't tell the difference) and even if it was used for smoking cessation purposes, wouldn't it behoove the insurance company to promote healthy lifestyles, like smoking cessation and if it can be done effectively (proven in multiple randomized controlled studies) and less expensively by using generic Wellbutrin instead of Zyban, then it would be better for everyone? The line of questioning was galling to say the least. They finally did approve my request after spending nearly 20 minutes on the phone. All I could think of is, "what a waste of my time." And speaking of waste, what are these pharmacy benefit managers doing trying to put a huge barrier between me and my patient? I spent nearly 30 minutes in the patient visit to explain the risks and benefits between all the antidepressants and I have to deal with some pharmacy benefit manager why I'm not prescribing Wellbutrin for smoking cessation purposes? They might as well just tell their patients what they can or cannot take, not taking into account the past medical history, allergic reactions, so on and so forth. Take the doctor out of the equation because we're just wanting to prescribe the most expensive medications because we watch so much of those ads on TV telling you the greatest drug there ever is (except in the small print or fast speaking because there are some side effects. Oh never mind).

I generally don't mind helping patients deal with their insurance companies; but there comes a point where things get so absurd and it will only get more absurd because the doctor-patient relationship is no longer considered sacred and important anymore. I know that there are some questionable doctors out there that might be spoiling it all for everyone else, but the current system (see my diatribes below) feeds to the dysfunction that is occurring everywhere. There is so much evidence (much of it in European and Asian countries) that show the benefit of a good doctor-patient relationship (when it comes to antibiotic use/misuse; malpractice), but nobody here seems to want to foster that relationship here in the US. Again, it's all words, but no action. There has been no significant recent legislation that demonstrates how important it is to address this situation (with maybe the recent announcement that Medicare is revising and increasing the physican fee schedule with the intent that they value doctors spending more time with their paitients).

Also yesterday, I was dealing with a problem with Oregon Medicaid insurance that has been on my backburner for several months, thinking it would go away somehow (but of course, it never does...Murphy's law). There was a patient of mine that has Medicare as his primary insurance but has a thing called a Qualified Medicare Beneficiary (QMB) program that is under the auspicies of the Oregon Medicaid program. It used to be that he was qualified to be on Oregon Medicaid which was not a major problem as I see patients that are on a managed health care plan that receives funding from Oregon Medicaid. The straight Medicaid (or open-card, as they call it here) pays very, very poorly from every standpoint of reimbursement ($20-30 dollars for a 30 minute or equivalent visit) . But if I see someone on the managed care Medicaid, I get paid better (not by much, but better). I don't know why there is a discrepancy. I also don't know why if someone doesn't qualify for Medicaid, why they can be on the QMB program and be treated like a Medicaid patient (in terms of reimbursement) anyways, which I'll explain next.

Anyways, this patient somehow no longer fit the income requirement for Oregon Medicaid. He made too much money. But now they placed him on this Qualified Medicare Beneificiary (QMB) program that is supposed to cover for the copay, co-insurance, and deductibles. What they neglect to tell providers that they ask the providers to subsidize the care of these patients because they (Oregon) don't actually pay the copay, co-insurance, and deductibles. They determine how much you get paid based on the poorly reimbursed Medicaid fee schedule (described above). So let's say that you charged a visit for $100 for Medicare. Medicare only pays 80% so you get $80 and the $20 remaining is the patient's responsibility. But if they have this QMB program, the $20 is supposed to be paid by Medicaid. But not as you would expect. Since the equivalent cost for a $100 Medicaid visit is $40, then they are not obligated to pay more than what you received by Medicare ($80). They claim that since I do see Medicaid and Medicare patients that I have relinquished my ability to balance bill the patient and I have to follow these rules. I know that I have chosen to see the patient but the whole logic of the reimbursement scheme seems quite absurd. So, what they actually claim and what they actually do is two totally different things. What it comes down to is that as the provider, I subsidize their care. Given that it's only one of my patients so far is not such a big deal. But let's say Medicaid continues to lower the income requirements which mean more and more Medicaid patients no longer are on Medicaid (which is actually happening right now) and happen to be on this QMB program, you can see where this is going. All these struggling primary care physicians will be shutting their doors because they can't afford to practice anymore.

I went into medicine because I wanted to help people. I also do make a living being a physician. But one cannot continue to be a physician if their pay is getting diminished by this system of legalized extortion and bribery. It's the old adage, one cannot help others if one cannot help oneself. I look around and see all these different services offered (dentists, optometrists, car service, sewer service) and I am puzzled every day to see that what I get when I provide my services, is less than those services that I just mentioned. I knew that going into medicine and I went into it with my eyes wide open. The state of affairs were already a mess. What I didn't expect to see is how nobody seems to want to do anything about it. Either family physicians are in complete denial (and I do suspect that academic medicine is in some ways about not seeing the problem) or we are too stuck in our old ways that we cannot imagine what it would be like in any other system. The "good ol' days" are gone.

You're probably wondering then, "If I'm so unhappy about the situation, why don't I do anything...like go into the local chapter of the American Medical Association or American Academy of Family Practice, and so on?" Well, I know myself and I have been in situations where there is politics. Being a chief resident several years ago gave me the insight I needed and I know myself better than I had been before I had done it. I realized that I'm not really a political person in that sense. I am very opinionated, but not political. I tend to want to do things and make change rather than just talk about it. So therefore, that is what I am doing...doing my own medical practice the way I want to do it and the way I feel things should be. I also know that I have to accept the negatives that go along with it (running your own business for example, being on your own, feeling isolated and all that good stuff) and knowing that there are the things that are beyond my control (like public policy, legisations, rules, insurance, people). Just like one of the 12 steps for Alcoholics Anonymous, "Accept the things you cannot change, and know the things you can."

Friday, May 19, 2006

My Diatribe

This is a continuation of where my story ends off as mentioned in my website (under "History" and "Practice Stories")

What I had seen, experienced, and read about during my years in college and medical school (in the 1990's) was the decline of the United States health care system over the past several decades. Although there were good intentions by all (physicians, government, health care administrators, insurance companies) to try to "fix" the system, we are now left with a fragmented health care system that does not effectively address the spiraling cost of health care. Symptoms of this ailing system are increasing health care costs and decreased access to care. What I believe are the major problems with this current system stem from four major factors. These are (in no particular order):

1. Over-specialization
2. Lack of focus for preventative care
3. Medical malpractice
4. Over-reliance of pharmaceuticals.
(I suspect at this point in the diatribe, there is going to be a lot of flaming going around).

Overspecialization limits access as patients usually have multiple health issues and no one specialist can address all of them in an effective manner. This is where a primary care physician can provide efficient care. Unfortunately, physician reimbursement schemes in the United States do not provide incentive to support primary care providers. In fact, it is driving down the number of providers, limiting access to care even further. Some of the evidence for this includes a decrease in matched residency positions for the primary care specialties reflected by a decrease in interest by medical students. There is also a decrease in active primary care providers due to burnout. A recent article from the American College of Physicians reported that unless there is a significant change in health care policy, we will see the collapse of primary care as we know it. I believe there there is too much emphasis on specialist care and not enough on holistic care. Don't get me wrong...specialists do play an important role and they must be compensated fairly but there must be some equality and fairness to the reimbursement scheme. If there is any serious effort to fix the decline of primary care, the reimbursement schemes must be adjusted to reflect that. Otherwise, it's all lip service. These schemes are developed and based on rules set up by Medicare (relative value units and such). Only through governmental change can this be trend be reversed. Unfortunately, I also believe that the US government has become inextricably linked to those with the money (special interest groups and lobbyists) that make it difficult for any such change to happen. But that's for another topic...

Lack of focus on prevenative medicine and services continues to be a sore spot. It's all talked about on the news, the medical journals, on TV, but there is nothing that indicates any significant policy change that suggests that we have turned the corner. For instance, it was only just in January, 2005 that Medicare had recently started covering for preventative care services, but even then, it is very limited in scope. However, preventiative services start at the beginning and that means children. The disheartening thing about our current health system is the increasing number of uninsured children. Where I work in the urgent care, I see so many children that could have had preventative services and adequate management of chronic illnesses such as asthma so that they could avoid a major hospital bill. I see frightened families who are unable to afford basic medical care and only until they are near death's door do they go to the hospital in desperation. The cost of desperate care is always more than the cost of prevention. To remedy this, there must be incentives to place a higher value on prevention (or even have coverage) by the payer, whoever it may be.

Medical malpractice is also affecting access to care as physicians are under economic pressure and practice defensive medicine which both increase health care costs. When did this become a crisis? There are some that believe that doctors have become less trustworthy. There are some that believe that the medical malpractice insurance companies are inflating premiums that don't reflect the number of malpractice payments. I think its probably both. There is a perception by patients, and rightly so, that doctors are not as trustworthy and this goes back to the lack of a doctor-patient relationship. We try our best, but given the economic model of our current health care system, doctors are driven to see as many patients as possible in the limited time that we have. How can one possibly establish a meaningful relationship in 5 to 10 minutes? Unfortunately, that appears to be a norm rather than the exception in these times. When there are less primary care doctors available (see above), how can such a system survive? The only result is decreased access to care. Patients aren't able to be seen in a timely manner and when they do, they only spend a scant amount of time with their physician. No wonder patients are skeptical. If that were the case for car mechanics or any other service industry, I'd be fuming! It's no wonder that patients just resort to going to the emergency department because they can't see a doctor. This affects everyone because the costs of the ED visits just gets passed down to the ones who can pay. What that means is that for every uninsured person who receives essentially subsidized care, that subsidy is paid for by the insurance companies who then passes down that responsibility to those who can afford health insurance (businesses or individuals). Which leads us to the concept of increased cost.

The significant influence of the pharmaceutical industry cannot be denied. The amount of money that is poured into advertising as well as direct-to-patient marketing translates into spiraling costs of medications. The temptation by physicians the use the newest drugs further fuels the fire. Besides patient marketing, there is heavy physician marketing which further influences prescribing and treatment practices. There are few things about pharmaceuticals I have observed which I have no particular answers to. There are proponents from the pharmaceutical industry that say that the high cost of new medications come from the research costs. However, there is pretty good evidence that suggests that research only contributes to a smaller percentage of the product's cost and the majority goes into marketing. Big Pharma also states that most of the research, development, and production of the medications come from the United States; but from my own scanning of pharmaceuticals; the majority come from other countries when you read their "Made in" labels (i.e. UK, Canada, Japan, France, amongst the ones I've seen). Seems kinda fishy to me. What's even more of a travesty is that when I cross the border to Canada, there are equivalent medications (i.e. Zyrtec in the US) that are now over the counter and cost nearly 10 times less than the US equivalent ($4 as opposed to $40 for the same quantity!!). So when there are people who say that drugs coming from other countries besides the US do not stand up to the same rigorous testing and quality standards (i.e. the FDA), and therefore are inferior; or it takes more money in the US to develop and create these medications; all of these arguments are so hypocritical...especially when the drugs that are sold in the US (approved by the FDA) are made from these "different" countries. Furthermore, it makes no sense to me that the nonsedating antihistamines need to be so expensive and still need a prescription when the ones that are over the counter (like Benadryl) have serious side effects (sedation) that put patients in danger if they are not careful (driving). Can't help but feel puzzled by that either...

The take home message from all of this is that I think that there should be no "business in medicine". Health care should not be "for profit". That includes medicines, research, health care. To be "non-profit" doesn't mean that those in the health care field should not get paid. It means there there should not be any CEOs making billions of dollars in take-home pay or any participant in the health care delivery system (physicians, insurers, consultants, pharmaceutical companies, medical technologies, electronic medical record vendors or programmers) that think that there is a "killer" profit that will increase their stock options when they do anything health care related. I think that capitalism has run amok in the health care industry because it is so easy to take advantage of people willing to find that magic pill or treatment. The fact is, there should be no temptation in health care delivery because I believe it is unethical to tempt people with a treatment that they cannot necessarily get because they don't have enough money; unfortunately, health care in the US is all about the have and the have-nots. It's a cruel reality. We have a very ill medical delivery system and it's on life support. In subsequent posts, I'll be discussing more about what I've done as a solo family physician to "survive" on this broken system and what got me there in the first place.

Wednesday, April 26, 2006


This is the first posting of the About Family Health Blog site. This will be the place where I will be accounting my experiences and opinions about life as a solo family physician in Portland, Oregon. To start off, here's the link to my clinic website: http://www.aboutfamilyhealth.com.