Monday, October 8, 2012

Medicine needs to join the 21st century

Last week, I wanted to start a new medication for my patient.  Her insurance company didn't want to cover it.  So, I called her insurance company to argue my side.

After listening to some awesome (not) hold music, I got to speak with an automated system that asked for information about me and my patient.  Okay, this was kind-of impersonal, but it wasn't particularly offensive to me.  Then more awesome (not) hold music to speak with a "representative."

The representative introduced himself by his first name.  Perhaps he was having an off day, but his customer service skills were a bit lacking.  He also appeared to have very little medical knowledge; he read through a list of conditions that this particular medication is approved for, mangling most of the pronunciations.  After answering "no" to this list of 20+ conditions (and assisting him with pronouncing most of them), I was put on hold again.  Yep, more awesome (not) hold music before being informed that the pharmacist declined my request. Next step: wait on hold again to finally speak with a physician in peer-to-peer review.

I want to be responsible with costs for my patients and the health care system. I'm sure at times I am wrong, and a more affordable alternative with equal efficacy exists.  It's not that I'm unwilling to hear that - I would just desperately prefer a more efficient way. I didn't need an insurance company representative to tell me that my request wouldn't meet their usual criteria, but I had to be officially "denied" before I could speak with a doc who could override it.  Why must policing medication costs involve sucking time away from busy primary care docs who don't have that time to spare?

Although I am unhappy with this particular episode, my goal is not to vilify insurance companies; they also have a job to do, and many of my patients benefit from their services.  Let's face facts; physicians are our own worst enemy when it comes to the outrageous spending on health care in the U.S.*  As physicians, we need to stop blaming the insurance companies for the need for these reviews and take responsibility for the costs of what we prescribe.  We need to encourage better interfaces among all players in the health care area.  Our patients need us to work collaboratively with insurers to make their care better.

Insurers' scrutiny of our prescribing is not likely to go away any time soon, though, yet the problem with these medication reviews is not the company representatives or the awful hold music; it's the phone process itself.  It's the 21st century, yet we're using the telephone like it's 1950.  Maybe that nifty 20th century invention, the computer, could do better...

How about an automated cost-rating system for physicians within insurance companies? Maybe if you're a "red flag" doc who frequently prescribes unnecessarily expensive drugs and treatments, then you have to be go through peer review more often and maybe even do some extra CME on cost containment.  If your track record shows mostly low cost interventions, though, then perhaps you get a free pass or two.

How about an online review process?  Insurance companies could be super-transparent about the covered conditions, and if your request didn't fit, docs could immediately send a HIPAA-secure message to peer review.

Health care reform must include simplifying the processes that waste resources; and, yes, physician time is a valuable resource.  This frustrating, inefficient process of getting medications approved is among many others contributing to our skyrocketing costs, aggravating insurers and docs, and discouraging students from a career in Family Medicine.  We will need more family docs in future years, not less. And, we will need them actually practicing Family Medicine instead of listening to awesome (not) hold music on the telephone.  

Surely, together, we can find a better way.
CME = Continuing Medical Education.  Most medical specialties require so many hours of CME every year to maintain your board certification.
HIPAA = Health Information Portability and Accountability Act:


  1. Jen, I am sure that you were doing the best thing for the patient, because I know you care. Sometimes there are doctors who prescribe the newest thing because they think it must be the best no matter what, when the patient might be willing to accept "pretty good" at a generic cost. Perhaps the insurance company thinks you are like our earnest pediatrician who prescribed my infant daughter an $80/month allergy nasal spray when there are $10 copay generics (I'm sure that $40 was in the fancy egg-shaped squeeze bottle lever design), or a specialist who prescribed me a $350/supply cream when a $3.25/supply generic pill would have accomplished matters the same way, and did just fine when the condition reoccurred. I paid for the $80 spray once, and never refilled the prescription. The cream/pill was a different matter, but I made sure I asked for something cheaper the second time around with a different doctor who wasn't using life-in-danger scare tactics.

  2. Kitty - whoa. No wonder insurance companies feel that they have to monitor what docs order so carefully.