Prescription Medications and Insurance Company Oversight Plans

From the perspective of a practicing physician, patient and consumer; the free pass Congress has given the pharmaceutical and insurance industries in health care reform drives me crazy. Yes I heard about the voluntary relinquishing of 80 million dollars by the industry. That makes about as big a dent in their bottom line as me urinating in the Atlantic Ocean and trying to raise the tide.

It is unclear why prescription medications are so much cheaper in Canada and Mexico and overseas?  What is even more unclear is where all of our prescription medications are being manufactured and how do our domestic standards actually compare to products sold across the border?   You never see Consumer Reports do a review article on the quality and safety of prescription drugs produced outside the Continental USA and the locally produced products?   You never see a cost analysis of producing these meds here and abroad.  Yes, you see plenty of articles on vitamins, minerals and herbal products but absolutely no credible studies on their efficacy and safety either.

If I have a major beef as a physician and consumer it’s with the firms health insurance companies hire to oversee their prescription drug plans. The insurance companies know well that most of their patients get their health and insurance and drug plans through their place of employment. They additionally know that most years the plan changes as does the patients general medical doctor.  You see a new patient who is  obese, hypertensive individual with high cholesterol and prescribe them a cholesterol lowering medication only to receive a fax from the prescription drug plan over-site company asking you if the patient has failed on the generic lovastatin and or pravastatin?   They will not prescribe the drug you prescribed, even if it is on the formulary, without first checking that data. Of course you don’t have that data. You know the patient has had five different PCPs in five different years. You may know that the patient had some muscle aches on simvastatin.  The insurance companies don’t care. They know that each time they throw an obstacle in the prescription process; the patient will reach into their pocket book 70% of the time, or more frequently, and pay for the drug themselves rather than wait for the review process.

Even quantities prescribed are an issue. The plans only dole out one months supply. Last month a patient of mine went on a midweek vacation about a two hours drive from home. Her life had been dramatically improved by the addition of Effexor XR for obsessive compulsive problems years before.  The drug helped greatly but if you miss a pill or two it produces a nasty withdrawal syndrome.   The patient, by mistake left her pill bottle at home. She called her pharmacist and asked if he could prescribe some of the medication for her at the local pharmaceutical chain outlet which was close to her hotel. He called me for permission and I approved. The problem was that the drug plan over-site firm had already prescribed a thirty day supply and would not approve the prescription.   How ridiculous. The patient paid for five additional pills at full price just to avoid the hassle.

It’s time for State Legislatures and State Insurance Commissions to put their foot down and start tightly regulating the insurers and the drug review companies. It’s clear our elected Congressional officials don’t have the backbone to do what is right for their constituents in the face of attractive campaign pledges. Thus, it’s time for consumers to act instead.

The Commandments of Physician Consulting

When I entered the medical profession in 1979 a wise and experienced internist taught me the lessons of consulting in the private world.  He told me to find a group of specialty physicians you trust and can communicate with.   He suggested that each time I send them a patient for an opinion, I communicate in advance with the consulting specialist and let him or her know what my concerns were and what questions I was asking.  Supplying the consultant with the available lab work and imaging data plus a concise history were important.  In those days most patients had minimal health insurance, of a catastrophic nature to cover hospitalizations, or they had none. They expected to pay for their visit. Sometimes you sent patients who could not pay very much if anything. That was all right as well because it was understood that if the consultant cared for your indigent patient you would send them a paying patient as soon as you could. At the same time, when they needed your opinion on an indigent patient you would provide it just like they had provided it to you.

When you received a consult you always thanked the referring doctor for extending you the courtesy of inviting you onto the case. You made sure to go see the patient in a very timely manner. When you had constructed your opinion, you called the referring physician and reported your findings directly.  You never just wrote a note and dictated a consult note and left.  You wanted to know the referring doctors concerns and plans and make sure the consulting opinion provided the answers the referring doctor needed to manage the case.

Very often family would request information from the consultant.  As a consultant you never spoke directly to the family without first obtaining permission to do so from the patient and the referring physician. You never wanted to upstage or criticize the care provided by the referring physician. You were never supposed to deliver clinical news and findings to the family BEFORE you discussed that information with the referring physician. It was very embarrassing to the referring physician to find out about a change in the patients clinical setting from the family via the consultant before you even knew about it.  In those days, we would arrange joint conferences with the family, the consulting physician and the referring attending physician if the family wished to discuss the case with the consultant. If the consult was an outpatient office based consult, the consultant made suggestions only to the referring physician in all non critical, non emergent, settings.  The only time the consultant would become the team leader was if the referring doctor asked him/her to assume care of the case. This did occur, but was never a surprise as it is today.

This culture of civility and collegial behavior changed with the rise of the insurance companies directing medicine. Reduced fee insurance plans set up panels of generalists and specialists. Your favorite two or three doctors to refer to in a specialty may very well “not be on the panel.”    When you now sent the patient to a different consultant to honor “the list on the panel” instead of them thanking you for the referral, you were more likely to be scorned for sending your full paying patients elsewhere but your discounted patients to the specialist on the panel. With the loss of civility over panels and plans came the loss of communication. Suddenly doctors were “too busy” to call the referring doctor with their findings and suggestions. They were too busy to suggest a diagnostic and treatment plan but had plenty of time to order tests and ancillary studies with their lab and equipment which was also on the plan before they discussed it with you.

It is long overdue for doctors to start using their cell phones and office phones and start communicating with their colleagues directly. Direct communication eliminates mistakes. Hand writing in the chart is difficult to decipher.  Talking provides for better patient care.  Despite the high volume and time constraints doctors need to be better direct communicators for our patients benefit. Consultants need to offer suggestions and opinions and only assume control of the case if they are asked to.  Referring doctors need to supply the consultant with the reason for the consult and the data to analyze it. The culture of communication needs to improve.

Whatever Happened To Nursing Care and Communication?

When I completed my training and joined the staff of our local community hospital to practice General Internal Medicine, every floor was run by a charge nurse. I had learned in medical school and during residency that if you wanted to get things done in a timely manner and get nights sleep while on call, you learned the rules and regulations on Mr. or Mrs. Jones floor and followed them.

In the late 1970’s and early 1980’s when you arrived to make patient rounds, the floor nurse would gather the medication list, the patient vital signs and go with you to the bedside. You would greet the patient, take a brief history, perform an exam and discuss the problems of the previous night with the patient and the nurse. You would receive a direct verbal report from the day shift nurse or departing night shift nurse of the patient’s concerns and the nursing staffs’ insights, thoughts and concerns. By the time you moved on to the next patient you had answered all questions, reviewed all medications, discussed the plans and goals for the day and reviewed the lines of communication .  These nurses had graduated high school and gone on to a two year nursing school. They received on the job training and supervision from senior staff who had been working at that hospital on that floor for decades. These nurses could change a sheet and bedding on a patient immobilized in bed in traction. They took vital signs by holding the patient’s hand and looking into the patient’s eyes and feeling if the pulse was healthy and brisk and if the hand temperature was warm and dry. The therapeutic nature of the hand holding and human touch was grossly underestimated by administrators and economists

In the mid nineteen eighties, as health insurance companies began to rule the care of patients at a discounted rate, things changed. At the local corporate hospital nurses stopped coming to the bedside. In fact they stopped getting a direct verbal report from the outgoing nursing shift.  The outgoing shift left their report on tape recorders for the incoming shift to listen to when they had a chance. Gone was the stability of tenured and experienced nurses replaced by per diem nurses from temporary agencies who could be practicing in one hospital on Monday and four others the rest of the week.  These nurses might be seasonal employees flown in from Scandinavia or Canada to service the increased winter seasonal volume in South Florida. They were no longer great care givers. Most of them were now going from high school to four year colleges to study nursing. Many were then encouraged to go on and get graduate nursing degrees.  Nurses with a four year degree were not looking to empty bed pans, change bedding or even change bandages unless wound care was their designated specialty. Outside the critical care units, they were primarily administrative, directing “aides” with little or no formal school training and no nursing school training. BP cuffs were replaced at the bedside by robots. No longer were hands held to check vital signs. No longer did the nurse have time to go to the bedside with the doctor to review the patient’s progress and identify the problems and goals for the day.

They became so well educated that nursing couldn’t keep them in the profession. They wanted more. They became physician assistants and nurse practitioners so that with their advanced degrees they could be given more clinical responsibility and allowed more clinical decision making. The problem is that they were not given the formal training one need to have to make these decisions. They were not given the arduous clinical oversight of a large volume of cases one needs over a prolonged training period to become a trained clinician.  They were supposed to assist primary care doctors and generalists and expand the ability of our small primary care population to see patients. Unfortunately, these PA’s and NP’s soon realized that there was no money in primary care and most generalists could not afford to employ them anyway. It was much nicer to work for a plastic surgeon and orthopedist and do their entire pre op and post op care so they could stay in the OR and generate more revenue. It was much easier to leave the bedside and go work for hospital administration or a medical equipment manufacturer in sales then become a supervisor of under educated aides while filling out paper work all day long.

I miss the days of going to the bedside with the nurse and the medication sheets. We made fewer errors. The communication and rapport were better. The nurses were our eyes and ears watching and caring for our patients while we were in the office. The technology and training was supposed to improve communication not make it more difficult. I would love to see the two year nursing program for care givers return. We need doctors and nurses going back to the bedside. We need nurses who are allowed to care for patients rather than supervise others and fill out checklists.

Healthcare Regulations ……………….

I went to see my patient recovering from major intestinal rerouting surgery called a Whipple’s procedure at a local skilled nursing facility. The surgery was performed at the University of Miami Miller School of Medicine Jackson Memorial complex to remove my patient’s pancreatic cancer and extend his life. At eighty years old I had advised against the surgery because I thought the recuperative period would eat up most of the time this elderly and chronically ill gentleman had left. The patient chose to go out fighting and found a surgeon willing to do the work at a Center of Excellence.  After five weeks in the Surgical Intensive Care Unit at Jackson Memorial Hospital the surgeon transferred him directly to our local rehab nursing facility. He had two intestinal tubes in place with one providing hydration and nutrition, was not strong enough to swallow on his own and couldn’t lift his head off the pillow because he was so weak.

Caring for patients at a nursing home is a responsibility of the profession but clearly is fraught with disaster. The ratio of nurses to patients may be as high as 1:40. The quality of the nurses is usually no where near as good as you see in your community hospital or office.  The first thing you notice on your way to the SNF is that everyone is looking to sue them for elder abuse.  The buses are lined with huge advertisements suggesting that your loved one should sue for damages if they were hurt at a facility. The phone book cover shows trial lawyers recruiting you to sue for elder abuse. The television ads encourage you to sue for elder abuse. To say that these facilities are under pressure to produce is an understatement. Regulation after regulation at the State, Local and Federal level is in place to insure the health of your loved one. In fact there are so many people looking after the rules and regulations you wonder if there is actually anyone left to take care of the patients. So much money is devoted to dotting “I’s” and crossing “T’s” that, when do they actually have time to interact and nurse the patients?

If you look at the census of patients at these facilities there are generally two types. Both are usually elderly and infirm. One group is recovering from an acute hospitalization and hoping to recuperate and return to their life in their home. This is a temporary stay for them. The other group is custodial and too infirm to be cared for at home. These are elderly people in the last stages of life who deserve comfort, care and the best quality of life we can provide them as they live out their life. If only it were so simple. All the rules and regulations make it difficult.  If mom scrapes her knee and needs some peroxide and a band aid with an ice pack, nothing can be done without calling the doctor first. If “mom” has indigestion from a spicy meal, she can’t take a Tums or Rolaids without first calling her doctor and obtaining an order. If dad wants to eat a cookie and he is on a diabetic diet, he can not eat it until they call his doctor.  It doesn’t make a difference what hour of the day it is. I routinely receive calls at 3AM saying, “Dr Reznick I am sorry to call so late but Mrs. Smith slipped and went to the floor on the way to the bathroom. SHE HAS NO APPARENT INJURIES but we are required to call you and inform you. Good night.”

If a poor patient actually gets sick with a cough and a fever and is having no respiratory distress the facilities first activity is to “Dial 911 and copy the chart for transfer.”  By the time they call a physician, the patient is in the ambulance on the way to the ER. The thought of examining the patient and getting vital signs, listening to their lungs, checking for consolidation, getting a bedside O2 saturation is not in the vocabulary of my local SNF’s.  Giving some Rocephin and starting a Z pack with gentle pulmonary treatments is unheard of. It’s always 911 and off to the ER.    The Fire Department doesn’t complain because the more trip-runs they make the higher the budgetary allowance they can ask for next year. The ER doesn’t complain because these are Medicare beneficiaries and Medicare pays well in Florida. The only ones who complain are the parents of the infant who was found apneic in his crib and the response  time by 911 is delayed because they are carting a demented 95 year old with a cough to the ER instead.

This all occurs because of liability and over regulation.  It’s time for some common sense to prevail. These facilities need fewer regulations and more staff to provide hands-on, day to day care. Medicare funds should not be used to pay for these patients unless there is a living will and or medical directive and or health care surrogate who clearly designate the patients’ resuscitation status and health care goals in advance of a crisis. Care should be provided at the facility with the ER used only for those patients who need an acute care hospital to relieve their pain and suffering and have designated directly or through their surrogates that they want to be sent back to the hospital.

Let the facilities spend money on care instead of bureaucracy. Let market forces and word of mouth and Internet websites like “TripAdvisor” for hotels be created so people can discuss where the care and service are good and where it isn’t.