It seems like every day some entity wants to question my medical judgement. I am not a perfect doctor but in the grand scheme of things, I know my patients’ health needs better than their insurance company, the government, or their employers. The constant interruptions by individuals who want to believe their algorithms fit every patient does little to serve patient care and much to reduce my efficiency. To make a point of how often this occurs, I’ve decided to TRY to document each interruption, within the confines of my limited time. Here is todays irritation:
PBM (pharmacy benefit manager) requires a PA (prior authorization) to refill digoxin. Patient has been on digoxin forever. It is a med that is rarely used anymore, though was once commonly prescribed for congestive heart failure or rhythm control. Unfortunately it has some negative side effects and typically there are better drugs for the conditions it is used to treat. However, in this case, patient came to me on digoxin. I sent her to a cardiologist to see if she could substitute another drug. She was intolerant to other medications and ultimately the cardiologist felt that digoxin was the least risky choice and continued it. This was last checked as recently as two years ago.
Sigh. PA applied for.
Laying in the recovery area I sneezed, hard, five times. My right nostril burned. I pulled the oxygen off and asked my husband what the O2 measurement showed on the monitor above my head. “94% – it just dropped 3%”. I took deep breaths and the number popped back up. As my nurse walked into the room, I requested removing the oxygen measuring device from my finger. She said “Let me get one more set of vitals”. I sneezed a few more times, my nose running and burning.
Coming home that afternoon after my colonoscopy I continued to sneeze, the burning sensation in my right nostril got worse and the runny nose persisted. It was time to do what any competent physician (or e-patient would do) – I googled it. Apparently this is a common problem after colonoscopy these days. It turns out that with the addition of using propofol for colonoscopies, anesthesiologists insist that a high flow rate of oxygen be used during the procedure to reduce hypoxia (a low oxygen level) and the use of capnography, or measurement of carbon dioxide retention. In order to do this, as best that I can ascertain, they pump oxygen in one nostril and measure CO2 in the other. That’s a lot of hi-flow oxygen going into one nostril through a nasal cannula. There are studies related to the irritation this causes in patients as well as a reduction in patient satisfaction. It’s day three after my colonoscopy and I am still sneezing, my nose still burns and I still have a fair amount of rhinitis. Yeah, I’d say that’s a dissatisfier.
Just a heads-up to my patients about to undergo your routine endoscopy. The misery may not end once your bowels are back to normal. Take plenty of kleenex.
1. Li N-L, Tseng S-C, Hsu C-C, et al. A simple, innovative way to reduce rhinitis symptoms after sedation during endoscopy. Canadian Journal of Gastroenterology. 2011;25(2):68-72. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043006/
Flying home from the first HIMSS Patient Engagement summit, I finished Atul Gawande’s book, Being Mortal. I found myself aggregating my thoughts on the conference and the book. They both highlighted how slowly medicine embraces change as we struggle to put patients at the center of the healthcare stage. My reflections revealed that as far as I’ve come, I’m still not there in many interactions with patients. It’s still difficult for me to be more than “Dr. Informative”, which is Dr. Gawande’s accurate portrayal of physicians who are uncomfortable with medicine’s previous paternalism but unsure how to unravel the patient’s goals. During the conference patient panel, Kym Martin, a patient experience expert and four-time cancer survivor, commented that health is not just about the disease process. Physicians, indeed healthcare as a system, must consider a holistic picture that includes financial status, relationships, family support, work issues, etc. Present provider and hospital goals seem to concentrate efforts on what what we, the system, identify as the patients’ goals. Those “should bes” in our eyes are often not the reality of a patient’s existence if all circumstances are taken into account. Dr. Gawande struggles to remember to ask the following of his patients: “What is your understanding of the situation and its outcome? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?” And while his book is concentrated on end of life decisions, isn’t this true for all our patient interactions? Then at 10,000 feet over Chicago it occurred to me–wait, this was what I was taught a million years ago in Family Practice residency–to understand the patient and all that individual has to deal with, not just the disease AND to guide that person through the tangle of the healthcare system. Now if someone will just tell me how to do that in the seven minutes I have with them…
Mrs. Davis hasn’t seen me in over a year. It’s a burden for her family to bring her in but I haven’t yet been able to add house calls to my busy schedule. She recently turned 94 but lost the gift of cognizance some time ago. It’s only been a few months since her husband passed away though it is unlikely she is aware of that fact, she’s long forgotten who he was. She was once a respected professional, well-known in our city and a philanthropist of several now forgotten causes. She shuffles into my office, sitting with her head in her hands. She knows who she is, but that is all. She is well-cared for by family members who call themselves fortunate to share her home.
I look at her vital signs. The 15 pound weight loss jumps out at me. “Is she eating?”. Her caretaker responds, “bits and pieces of this and that, she’ll drink an occasional Boost”. “Does she appear to be in any pain?” “No, she sleeps a lot, doesn’t interact much.” I perform a not too-detailed exam and determine that she has no skin breakdown. In addition to her cachectic appearance, I notice a difference between sounds in the two sides of her lungs. One side sounds dull, though she breathes shallowly and perhaps it is the other side that is hyper-resonant. I look at her caregiver who is also a nurse. “She’s lost a fair amount of weight and there is a difference between the two lungs when I listen.” We lock eyes. After a few moments he responds, “And what would we do differently if we explored this.” I look at the patient. She looks a little tired but not uncomfortable. “Nothing, I would hope.” “Then we’ll be saying goodbye and thanks for refilling her meds.” I nod, ask him to call me with any problems and move on to my next patient.
The definition of irrational behavior is “without the faculty of reason; deprived of reason” and it is presently rampant in my workplace. Every patient seen, not just individuals with fever or nausea and vomiting, is screened for exposure to Ebola. Every patient that walks through the door gets a(nother) form with three checkboxes asking if the patient lived in or visited a west African country within the last 21 days or was exposed to an individual who has the disease or is at risk of having the disease. I guess in a world where hype and panic prevail this is considered a reasonable question. Along the lines of this thinking, it would make a lot more sense to ask:
- Did they drive to the office? —chance of dying in a motor vehicle accident 1/491
- Do they have a gun at home? —chance of suicide using a gun 1/203
- Are they flying anywhere in the next week?— chance of dying in an airplane 1/8335
- Did they run to their car or home in a thunderstorm recently?—chance of dying in a storm 1/83709
Chance of dying of Ebola: 1/3,934,300
I await the unlikely event when one of my patients returns from an Ebola-affected country in the previous 21 days and comes to me for his hypertensive check. As I enter our newly created isolation room and do the visit in full protective gear, recognizing that touching an asymptomatic patient is of absolutely no risk to me, what in the hell am I going to say to this gentleman? “Have a nice day and please slink out the back door on your way out?”
System administrators and politicians feed into the hysteria of the masses and frighten patients who are already freaked out by any number of irrational fears. As a consequence, heroes return from working in West Africa and are greeted with the loss of civil rights based on fear instead of science. I take umbrage at being forced to add to public paranoia by legitimizing a workflow designed for a real threat instead of this farce.
Answer: When the insurance company decides it is not.
A Healthcare Puzzle
The definition of screening, from a health prevention viewpoint, seems pretty straight forward: “a strategy used in a population to identify an unrecognized disease in individuals without signs or symptoms.” Typically these services are covered at 100%. However, insurance companies avoid appropriate payments for their members by changing the coding of a preventive service (which is covered 100%) into a diagnostic procedure, which is paid based on whatever the patient’s coverage allows. This change in coverage occurs because a polyp is found during the exam, which is of course, the whole point of doing the procedure: Screening and removing a polyp so that it never becomes cancer. Patients with high deductibles suddenly owe several hundred dollars in unexpected healthcare bills for a procedure they were told was covered. This is ethical and appropriate corporate policy?
And I can’t help but mention that the insurance company fancying itself a “Healthcare” company, promoting health and well-being, is the worst offender.
Subsequent colonoscopies that must be done five years later for individuals with polyps, instead of ten years, can arguably be called diagnostic. But changing the definition of a procedure solely to avoid paying for an appropriate screening exam, is another example of non-transparency, regardless of how well you explain it in the patient’s policy description.