[In the Land of Misaligned Incentives I]
I spent the better part of a recent week on a Pharmaceutical-Bureaucratic Roller Coaster that has become — both literally and figuratively — sickeningly familiar to me: a “no more medication left” clock ticking in one ear, while I was increasingly disabled by pain, a “[hopefully] leaving on vacation in a few days” countdown in the other.
The length, and the intricacy, of the chain between medication being prescribed and medication being delivered does something to explain why Americans pay more than any other people in the world for healthcare, for, on average, fairly mediocre results. It also points up the ways, and the degree to which, businesses have undercut, and largely made irrelevant, the expertise of a growing number of professionals.
Physician writes prescription -> Pharmacy queries insurance company -> Insurance company says, “no” -> Physician’s office provides “Prior Approval” (PA) and re-sends -> Insurance company says, “no”-> Physician sends “enhanced” PA
Lather, rinse, repeat: Scream!
This situation is neither healthy nor sustainable, for patients, for medical people, for our economy.
Did You Really Want to Prescribe That?
It is impossible today to run a medical practice of any kind without either a person or a team of people whose primary function it is to fight with insurance companies. The script is fairly standardized:
Physician prescribes medication or treatment plan; insurance company says, “no.”
The medical office and the insurance company do battle for a while, back and forth.
“Is that really what she wants to prescribe?”
“Yes, that’s really what she wants to prescribe.”
Odd question. Is, No, just kidding! that frequent a response?
Sometimes, the insurance company wants information or “supporting data,” justifying a medical decision — seven years or so of medical training and a decade or three of practice apparently not being enough to ratify the correctness of a physician’s decisions. But just as often, exactly what they want and in what form is something between opaque and mysterious. It feels less like the job is to coherently explain a medical decision and more like working out the right magical incantation that will unlock authorization.
“How much time do you, me and my staff need to invest in this process?” my physician emailed, of the recent debacle, wondering, “Is some clerical staff person looking for some key words or phrases on the PA [Prior Approval] that we haven’t figured out yet?”
He was engaged in trying to work out the appropriate type and dosage of pain medication for me (I’ve been having bone sawn and ground out of me for a decade or so now; ‘nuff said) and I think it fair to say that — as a medical school dean and someone who has won national awards for educating doctors on the safe and efficacious use of narcotic medications — his expertise in this area is greater than that of whoever kept reversing his decisions, whether that person was “clerical staff” or a Doc-in-a-Box, in the US or abroad, working with generic checklists of “when to do what.”
“Who is making these decisions?” my physician wondered. “What is their training? How are they making these decisions without talking to you or me or examining you? And why are they making these decisions?”
The generic answer is something like, “rules are rules.” We can insert, as well, some boilerplate about “best practices.” But . . . patients aren’t generic.
“The dose makes the poison,” (sola dosis facit venenum), wrote the Swiss physician Paracelsus, in the 16th century. But what constitutes a lethal dose for one patient may be the necessary dose for another. Easier — safer and more efficient — to make that judgment by (radical thought!) actually examining the patient, rather than carefully studying, and adhering to, inflexible, “one size fits all,” guidelines.
It took me a while to understand why a structure housing doctors’ offices is often called a Medical Arts Building, but that phrase contains a deep truth about the practice of medicine: it is a science; it is also, however, an art.
It should be noted, with regard to pain medication in specific, that while the past decade certainly saw an increase in dangerous levels of over-prescription, the great bulk of this was done by a relatively small percentage of practitioners; necessary and appropriate oversight should be targeted and precise, not broad and scattershot. Shutting down “pill mills” where people are tailgating in the parking lot is more than reasonable; using “the opioid crisis” as an excuse to crack down on everyone, both prescribers and patients is insane — and cruelly so: it is estimated that 100 million Americans, almost a third of the population, suffer from chronic pain.
The Cost of (Mis-)Managed Care
In part, the “Prior Approval” process is an artifact of managed care. Because physicians are the primary direct interface with patients, the theory goes, they can be susceptible to pressure, pressure to provide medications or procedures that may be anything between useless and dangerous. Put aside, for the moment, the fact that this assumes a pliancy in caregivers that I have rarely experienced. It also discounts years of training and experience, as well as ongoing professional education requirements.
This sort of oversight, moreover, is fundamentally misapplied to the current structure of our medical care system. Gone are the days of the sole practitioner, running the office with a spouse as secretary, receptionist, and bookkeeper. The great majority of providers now work for hospitals, medical groups, Accountable Care Organizations, all of which have their own guidelines and restrictions, all of which obsessively track the use of medical resources: time, procedures, medications.
Of course, this is on top of state and federal laws and the guidelines of both local and national medical societies — both mass membership groups like the American Medical Association (AMA) and more specialized groups like the American Academy of Family Physicians (AAFP).
Physicians, in sum, are not “insufficiently supervised.” Rather the opposite, I would suggest. And while I am in favor of efficient coordination of care and “evidence-based medicine” and reasonable oversight and regulation, that’s not what we have now.
While spending more on healthcare, per capita, than any other country in the world, we have a system that does not effectively serve the needs of patients, that does not sufficiently respect the autonomy of medical professionals, that enriches the business arms of the Medical-Industrial Complex, Big Pharma, and the Insurance industry, while the US — once a global exemplar — has fallen out of the ranks of the Top Twenty-Five countries with respect to quality of healthcare.
That’s just . . . sickening.