Thursday, May 14, 2009

You Have To Try This First!

The patient is agitated and intrusive. He shows up without an appointment, and when I say I'll see him, but he'll have to wait, he is not pleased. He knocks on the door while I'm with another patient. He's been off his medicines, and he's decided he felt better with them. I think we both felt better when he was on them. Oh, but he didn't like those medicines. He wants something else. He needs something else. Maybe he needs to be in the hospital? He won't hear of it.

Okay, go back on Old Medicine you've been on before.


How about Medicine X?

No. That stuff made his see dead bodies floating in space.

How Medicine Y?

No. Friend is on that stuff and it's awful.

How about Medicine Z?

No. Oh, you think that will help? Okay, he'll take that.

I think it will help. Oh, but then I remember that the state requires pre-authorization forms and I'm already behind here and there's all sorts of other issues, this patient isn't really in a great place for a detailed risk/benefit discussion, he's demanding something that will make him feel better now and I'm starting to feel his pain.

How about Medicine ZZ? I suggest a similar medicine.

Okay, he'll take that. In fact, he likes the name.

I write a prescription, he leaves and I resume my regularly scheduled clinic morning.

And then there's yet another knock at the door.

"But if you think that other medicine is better, I'll pay for it."

No, no, it costs hundreds of dollars, Just take the other stuff. Really, he's so bouncing off the walls that anything will take the edge off. The morning goes on. Yup, another knock at the door. The pharmacy couldn't fill the medication, not sure why. I've now drowned. I don't have pharmacies and calls to the state, and finding the right form, and pre-authorization phone calls and faxes...and whatever else it might take, in me right now and oh, he's not sure his insurance is even active. I surrender and grab samples (in the clinics, we save these for patients who have no other means of getting meds). He takes them and he actually leaves.

Next clinic day: Thank you, that medicine helped. The patient is much calmer, I don't once utter a word about hospitals. No side effects. And his insurance is now active. I write a prescription.

Fast forward to the next day. My cell phone rings, it's the pharmacy--- remember that patient (I do, but I see him at a clinic and I don't have access to his chart and why are you calling this number?). His insurance requires documentation that he's failed two other medications in the same class (and yes, those two medications both cost a small fortune as well, they aren't even asking if he's failed cheap meds!). I don't have a chart, but I think one of those meds made him see dead bodies floating in the air.

So let me get this right, I have a patient who was really sick, who's been in the hospital before, who is now better, and I'm supposed to take him off that medicine that's causing no side effects and put him on another, equally expensive medication---actually two-- and watch him maybe get sick twice, before I can put him back on the medication that is currently working just fine?

And how was your day?


Anonymous said...

Yes, and now think for a minute about how frustrated your PATIENT is, especially if s/he is not manic or psychotic enough to be fully aware of what's going on.

Sorry the paperwork makes your life tough. But consider how frustrating and awful it is for the patient, whose life stands to be directly affected. And not just by irritating knocks on the door during clinic day, or more paperwork.

Anonymous said...

I think I did consider how awful this was for the patient: I saw this patient 4 times in one day without an appointment (the same patient schedules and misses appointments regularly and stops his medications without discussion) in order to get him the necessary outpatient care before he got so sick that hospitalization was the ONLY option. I was respectful of his decision not to restart a medication that has helped in the past. I was respectful of the fact that he didn't want to take a medication that didn't agree with a friend. I didn't insist he go into the hospital when that would have been reasonable. I didn't argue that the medication the insurance company would approve probably didn't actually cause him to see dead bodies floating in space-- that symptom was more likely to be the illness than the medication side effect. And when he had trouble getting the medication, I handed him samples, valued at hundreds of dollars.

My sarcasm was aimed at the system that would demand that a working medication be Stopped when a human being's sanity is at stake.

Retriever said...

It must be exhausting. I like your description. And am impressed by your dedication, and the respectful way you worked with your patient. I agree that the way insurance companies hinder one from giving the treatment that a patient needs and can tolerate is absurd (as all too often the person ends up sick and in hospital as a result of penny wise, pound foolish protocols).

Our son is too sick for any private psychiatrist in our Gold Coast suburb to be willing to treat him (even tho we would pay the full price ourselves to one who would) , so at any given time there is one harried one at a kiddie clinic who is willing to. Who we forgive for not answering phone calls as he is a good guy and has at least 1300 young patients.

Almost anyone could start to feel a little paranoid after the insurance run around. It is hard enough for a person to admit that they need meds and ask for them (however ambivalently), but the roadblocks insurance puts in make it even worse.

As a parent, I have spent hours trying to reach doctors, insurance, and beg pharmacies to get a drug they are out of and are quite bland about not getting in stock again for three days. And the struggle to get drugs that don't cause the kid unbearable side effects, or that kid can even swallow. Being charged a hundred dollars more for a version of Abilify that can melt on the tongue, for example. Not to mention trying to get more of a drug when kid has thrown it up several times or thrown it out, and run out before the allotted time (insurance won;t pay if you refill early, even if MD okays).

The biggest change I have seen is that as our insurance pays less and less of the cost of the drugs, we actually pay more for his drugs than his therapy now. Of course it is cheaper than hospital.

Battle Weary said...

This is a perfect example of why quite doing medical billing and went back to school! Ex. from my end: patient came to an emergency work-in appointment sweaty, pale, complaining of chest pain, with rapid, shallow EKG won't be paid for because they have a history of anxiety?!? History of anxiety or needs to be checked!

insurance companies really suck.

Marie said...

This post is brilliant.

As a patient, I've stopped involving my insurance company at all because of the control they were trying to exert over my care -- at a point when I was STABLE and BETTER. Now I pay cash for everything. (Expensive? Yes. But did I mention I'm stable? One round with major depression was enough for me, thanks. Six hundred bucks a month on therapy and meds feels like a bargain.)


Thanks for showing us the frustration runs both ways.

itsjustme said...

I get your sarcasm, Dinah. I think you went above and beyond for this patient. It's criminal the way insurance companies operate!

SteveBMD said...

And to think that we, as doctors (well-educated, motivated, sympathetic, honest, hard-working-- well, for the most part, anyway) ALLOW ourselves to be treated this way. It's truly a shame.

Mr Ian said...

Agree with stevebMD.

I have always worked socialised health care so I'm curious about how Insurance companies, who are making clinical judgments as far as I can make out, make their decisions regarding the treatment choices and protocols etc.

UK has "NICE" who provide evidence based advise about best practice - which includes cost-benefit analysis and makes good sense. Clinicians don't have the time or resources to conduct those sort of analyses. The advice is made available to the clinician who retains authority to make a clinical judgment and is not mandated by that advice.

When the purse-holder has the final say on what choices the clinician has (which isn't altogether a bad thing), you'd want to know that those decisions are being made in a balanced and considered manner.

Do insurance companies have a statutory framework by which they must operate in making these restrictions & directives?

Is it driven by evidence based gold standards in clinical practice?

And how can clinicians get their hands on the evidence they use to inform their decisions to ensure it's Kosher?

Anonymous said...

This may well be one of your confabulated cases, but as a patient viewing this from a patient's perspective the first thing that pops out is that this patient, who you think looks in bad enough shape to suggest hospitalization, leaves with a prescription rather than getting a sample and a glass of water in the office. This patient who is so desperate as to be banging on your door, has to walk or drive to a pharmacy, then be told to come back in 2 hours to give them time to get to it, then be told the drug is out of stock, then have to go to your office again. This would be distressing on a good day. I can't imagine not giving this distressed person a sample on the spot if you had samples in the office.

Surely there must be a way to deal with insurance companies in a systematic manner. Do they print lists of drugs and which drugs a psychiatrist ought to prescribe and in which order? Perhaps the top 10 insurance company lists ought to be in a file next to the prescription pad.

Since drug companies pay physicians to test their drugs and only publish positive outcomes from tests, and they pay physicians to promote drugs, and they put propaganda out to the general public, it strikes me that a drug company would not stop there. I'd think they might give rebates to insurance companies for "pushing" their drug over their competitors by paying kickbacks for every time the insurance company forces a physician to change from one drug company's drug to their drug company's drug. Since the bottom line is dollars with an insurance company the bottom line would include not just dollars paid for the prescription but dollars directly from the drug company for a certain drug used.

Grumpy, M.D. said...

Yeah, this is such crap. I get it for all conditions. Med X is generic, but requires weekly blood draw, and somehow the insurance prefers it over Med Z just on a cost-per-pill basis.

Anonymous said...


Anonymous said...

You know what you do with the last straw?

Suck it up

Albi said...

If I understand correctly, it's all the same, you pay back and it was nothing.

Ivory said...

I know of several iterations of this with different patients, one who needed a $150 dollar part for their wheel chair, couldn't get it and developed sores that lead to a fatal bacterial infection. A less extreme example was my friend's daughter who had perfectly controlled allergies on All.egra and then was forced to switch to Clar.itin when it became over the counter. Two ear infections and an ER visit later, I wondered how much money had really been saved.

It's all a kind of human experimentation in a way. I think it should be illegal to pressure a patient to switch meds if they don't want to unless there is demonstrable harm to the patient.

The assistant said...

To Dr Grumps.... and others

Yup... i get all the time prior authorizations really a pain and really takes away me from me away the patients

but when it boils down to it, the MDs should be tending patients.

Also tell your Rx reps about the prior authorizations. Make sure you mention some insurance companies too. They usually give you more samples if you have a good report with them.