Medication Moments in Family Practice

Yes, that her “out” during
freshman orientation.

My younger daughter has a condition known as narcolepsy (she OK’d this post by the way). Because of it, she has a tendency to fall asleep any where and any time, but it is worse in the mid-afternoon. During college she was prescribed a medication called Provigil, which improved her ability to function in the real world, particularly in afternoon classes. Her classmates were a little disappointed at how well the medication worked as they could no longer tease her with drooling photographs taken during lectures. Due to the cost of the medication, she quit taking it while doing her present research job in Panama. Recently, she realized that her tendency to fall asleep in the middle of writing was interfering with her ability to finish her research paper. I’d heard that Provigil was now generic so I looked to see how much that would cost us, expecting some improvement in price. Nope it is still $26/pill if you pay without insurance (that is NOT a typo, with a prescription but no insurance coverage, thirty days of the drug will cost in excess of $788). WITH our Humana insurance, it would be a little more than $100/month, IF we could get a Prior Authorization on it. She bought it in Panama for $2 a pill. She did not need a prescription. I suggested that she stock up while she’s down there. Maybe she can get enough to last through graduate school.

Following that personal medication moment, I received a fax from RightSource, the prescription company owned by Humana. They wanted to know if a patient of mine who is taking a blood pressure drug called Bystolic was using insulin. Insulin, as you probably know, is a hormone important in diabetes and can be given in injectable form to diabetics. Bystolic is a type of blood pressure drug that can mask the symptoms of a low blood sugar in diabetics. The weird thing is, this patient is not a diabetic. Humana has yet to answer my request as to why they were asking me the question.


On Friday a patient came to me who is post-menopausal and having some vaginal dryness which is making intercourse uncomfortable. I suggested using a topical estrogen, specifically a drug named Vagifem. Many women prefer this form of topical because it is in a small pill that is much less messy than creams. Now here is where it gets weird. First of all, I could not tell the patient how much this prescription would cost her in the pharmacy because it is a “third tier” listed drug with Humana. She can look it up on line on the MyHumana site but I have no way of knowing. I do know it costs about $68/month if you don’t use insurance to buy it. There are no “generic” estrogen creams BUT Humana lists Premarin estrogen cream as second tier which typically is a $30-40 monthly copay. Here’s the kicker–if you buy Premarin cream without insurance it will cost you $150/tube (a tube will last anywhere from two to four months).

My medication frustrations this week were multi-fold–why do drugs cost so much more in the US than other countries (here’s a link to an interesting article in the New York Times that is old but still rings true regarding this question); why do I have to spend my time answering ludicrous questions for drug coverage companies in order to get my patients’ drugs refilled; and why isn’t there more transparency in medication costs for me and my patients?

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DPC, PHR, EMR, SoME and a couple other abbreviations

Watching the beginning of a training video for hospital administrators a couple of days ago made my head swim (and I can’t find the link on-line). It began with a gentleman walking his dog. Both he and his pet sustain minor injuries. They are sitting in the living room and his wife counsels her husband to see his doctor for an evaluation while she takes the dog to the vet. She calls the veterinarian office and is greeted with a real person who tells her to bring the dog right in. As she leaves her husband calls his doctors office and I’m already cringing at what I know will follow. Three minutes into the film (where it stops unless you want to buy), the gentleman is still on hold and has repeated his story to two different people. Meanwhile, the dog has already been seen by the veterinarian. This is getting better but it has been my personal experience and I hear frequent complaints from my patients. Fortunately they are less about my office than they used to be, so I think we are making progress. Rare the doctor’s office that has a real person answer the phone. It is discouraging to think that our pets get quicker, more empathetic care than we do.

Most of my Saturday was spent in the VA ER with a friend. It’s always interesting to be on the other side of the examining table. What I observed was the usual mix of caring and apparent disinterested staff. The individual I was with was in such pain he could not sit down. So for thirty minutes he stood, in obvious sight-line of three staff members. There was only one other patient in the waiting room at the time but it still took thirty minutes to get him processed and into the back. Once in the back, same scenario. No physician walked into the room for thirty minutes, it took another thirty to get him any relief. As I sat there being witness to this care, he said to me “Is this what a US single payer system would look like?” My thought was, “Gee, other countries do single payers well but can the US?” My French friends rave about their healthcare. My patients from Canada talk about how easy it is to get in to see their family doctor.

Lately I’m leaning more to changing how we reimburse primary care, rather than a radical change to a government-run payer system. The DPC system that David Chase discusses in Forbes makes sense to me.  As mentioned in previous posts, this is concierge medicine without the concierge price. For me it would be a win-win. I could see my patients for a reasonable monthly fee (which could be paid for by employers or patients) and in return they get more time with me and better preventive care. Add PHR (Personal Health Records), EMR (Electronic Medical Records) and social media to the equation and you have an opportunity for patients to become true partners in their care ( see the link to 6 things patients want from social media here).

Now if I can just convince my employer! 

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Reducing Fragmentation and Patient Care NOW not Next Year

I do not recommend doing this, but today I attempted to listen to two Webinars at the same time. One was also tweeting the discussion and the other had very detailed slides which made it easier to follow but as studies show, we are not really capable of that kind of multi-tasking. The topic of the first suggested it would discuss Primary Care and its future. However, what the expert proposed was a “How to” plan for bringing more customers into a healthcare system. This was boiled down to a recommendation that these system open small clinics, run by NPs, in competition with drug store and grocery store clinics of similar ilk in order to funnel patients into the listeners’ systems. The other Webinar was a discussion by three mobile health leaders (mHealth) on the future use of their products in the global mobile health arena (wow, that rhymed).
It’s is a good idea to know what is going on in the minds of healthcare system development teams and as I listened to the expert’s remarks I could not help but ponder on what, in my humble opinion, would build the kind of “team loyalty” that hospitals and other healthcare systems are dreaming of. What is it that patients want? I agree that they need healthcare access in their busy lives at more convenient times of the day than traditional physician offices offer. What my patients tell me (and what people tell me at cocktail parties) is that they would prefer access to their very own providers, those individuals who know them best. No insult intended to NPs because they are essential to the healthcare team, but they are physician extenders, not physician substitutes. What about developing systems that give patients greater access to their own providers? This would really engender loyalty to a healthcare system, especially one in which physicians are employees, more and more the norm these days. I believe mHealth can do that. What if you could access your physician after hours via Skype? Or text your doctor just for a quick conversation about whether you should seek immediate care or be seen the next day? Gee, what if the physician had access to their schedule and could book them on the spot?!? What I’m advocating here is a “concierge” type practice without the concierge price. Of course there would have to be some sort of reimbursement procedure to give already overworked primary care doctors the incentive to take care of patients in this way but wouldn’t that be a cheaper investment than opening the equivalent of “Little Clinics” everywhere?
Along with the cost, the second complaint I routinely hear from patients about their medical care is its fragmentation. From a patient and a primary care perspective, no one on the health care team is talking to each other. In fact, frequently the word “team” is a misnomer. Using tools like Doximity physicians can employ a HIPPA compliant platform to discuss cases and improve care. Of course the phone always works, but with the ability to ask questions and respond in a timely but convenient fashion, doctors and other providers like NPs, PTs, etc. can reduce the fragmentation patients feel from their healthcare team.
Of course I realize that ACOs (Accountable Care Organizations) are supposed to be developing this kind of care. But does the bureaucracy that surrounds these systems bother anyone else but me? Do we really have to wait for the lumbering movement of government sponsored programs in order to improve communication, fragmentation and access to care when the technology is already here today? 
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What’s my Worry Today in Primary Care?

Worrying about patients is part of my job. In these last couple of weeks it’s been a long-time patient with a life-threatening illness, a pregnant woman who didn’t want to be pregnant, and a young person who thinks that a pill will fix her out-of-control life. (I get a lot of older folks who are looking for that magic pill as well but they don’t worry me as much). Mostly I leave those thoughts at the office but sometimes they come  home with me. Lately what’s followed me home are patients who are avoiding treatment or visits because they have a high deductible or no insurance at all. Last week was a middle-aged woman who just got insurance after being without for several years. She had several concerning issues but the most worrisome to me was the thickened area in her breast. She didn’t tell me about it but on physical exam there it was–it felt wrong. It didn’t belong there. It was a little hard, a little irregular. Classic sensation for a cancer.. She hadn’t had a mammogram or a physical in years because of the cost. Would it have made a difference if she’d had one last year? I don’t know. Maybe. And maybe this “area” will prove to be nothing, though I doubt it. 

The number of uninsured Americans has gone up a few percentage points in the last ten years. What I am seeing more of are underinsured individuals–people with high deductibles and high premiums. These are the people who skip needed care because they can’t afford it OR they have the perception that they cannot afford it. They are “non-adherent” with medications because they fear the cost of followup lab tests even when their medicines are on the $4 Kroger list. They don’t come see me because they don’t know we offer a 35% price cut for cash paying patients. They equate health care with health insurance. They are aware of the skyrocketing costs of hospitals, medicines and doctors and fear that if anything is found on exam that they’ll never get insurance (a reasonable fear to have these days since many people are outright rejected and others are quoted outrageous premiums based on what are often minor problems). Or the patient may obtain insurance without coverage for a pre-existing condition.

I await the mammogram report with trepidation and hope she doesn’t skip it. She was concerned about missing a couple of hours at her new job. God forbid she lose the job that is supplying her with health insurance. I am sure she can’t afford COBRA. And if the worst occurs will she lose her job anyway because she can no longer work while going through surgery, chemotherapy and radiation? And then what?

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A Payment Quandary for Medicine and Social Media

These days I spend a lot of time reading other doctors’ and patients’ blogs and Twitter posts. One recurring theme is the use of Social Media to improve wellness in our patients. This is a great idea and I’m excited to participate especially when the data shows that patients who are on social media are already getting heath advice: PricewaterhouseCooper:

Consumer Activity on Social Media Sites Dwarfs that of Healthcare Companies, Finds New PwC Study on Social Media in Healthcare

But who will pay for this? More specifically, who will pay ME for this? Much as I enjoy answering patient emails, would love to have a professional Facebook presence and am happy to Twitter; all these things take time. And time is not something any primary care doc has much of. Since I do enjoy a life outside of the office, including learning a new language, spending time with my family, trying to exercise a MINIMUM of five days of the week, plus bear primary responsibility for feeding my husband and daughter, and would dearly love to read a book on occasion; in the absence of an obvious ROI (return on investment) to present to the healthcare system that employs me, how do I find the time during working hours to do these things and not get paid? My contract specifically defines how much “face-to-face patient contact” I must have. As long as the present reimbursement system persists when I’m not in physical contact with a patient I am not generating income.

As with any service industry it is difficult for our “clients” (I HATE that word, I have patients not clients), to understand that my pay is directly affected by how many people I see every day, or more specifically, how many RVU‘s that I generate on a daily basis. This is directly tied to how “sick” a patient is. So the sicker the patient, the more I can charge. Wellness? With the exception of ONE “well” visit per year for the commercial insurance patient, I am not paid to promote wellness or good health at all. Of course I try to throw that in with every patient visit but until primary care undergoes the revolution that it needs and deserves, prevention is not something I can afford to spend a lot of time on with patients.

And that truly, to use the vernacular, sucks. There are doctors out there doing it “right”, who have left the traditional practice model to become concierge doctors and by all reports these professionals are happier and more fulfilled in their jobs. My expectation is that this is the reimbursement model we will see in the future but in the meantime, how do I find the time to give patients what they want before they or the insurance companies and/or employers and/or government is willing to pay for that time?

modified 5-31-2012 (misspelled quandary–oops!)

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Specialist versus Primary Care

This morning a patient calls the office stating that his surgeon, who has been treating him for an abdominal wound that is still not closed, told him at his followup appointment that he needs to see a wound care specialist. The patient was instructed to call his primary care physician (PCP) and tell me to set that referral up for him. WHAT?!?!?!?! A few hours later my 28-year-old new patient tells me the orthopedist she saw this morning told her she had a kneecap problem, take Advil, stop running and get an MRI. When the patient explained that she wants to be an Air Force nurse and will have to go through boot camp, it was reiterated that she needs to stop running and maybe she broke her kneecap, so she should wait for the MRI. She has NOT had an injury and  BOTH knees hurt. She has noticed that after exercise her knees feel better. I spent five minutes explaining what patellofemoral syndrome is and suggested that she delay the MRI and see what routine quadriceps exercises do to improve her pain. I suggested substituting bike riding for the running but if running doesn’t seem to bother them, then she might just cut back on that and substitute biking. WHAT?!?!?!?!

This is not an uncommon experience for me. The first episode made my blood boil. AT LEAST once per week, many times more often, specialists tell patients that I will set up appointments, refill medications or interpret the tests that THEY did on a patient. If this occurs following a phone call to me BY THE PHYSICIAN HIMSELF, this is appropriate. But making the patient the intermediary is unfair to the patient, boldly rude to me and in a patient-centered environment, absolutely terrible care.

It is ironic to me that the individual who makes the least amount of money per patient in the doctor hierarchy, is more and more forced into the position of spending more time with patients to make up for, or frequently do, the job of the specialist. I love taking care of patients but I will NOT be used and abused by individuals who, whether they recognize it or not, are treating me like some sort of glorified physician-extender. 

Now I realize that the counter-reaction from the specialists is going to be that we, the first-line doctors, are sending patients to them without adequately working up the problem thus earning the label of “lazy intellect” from the specialist. I truly try not to do that. After all, that is the most interesting part of being a physician, the detective aspect of putting symptoms and tests together to try to make a diagnosis. That is one of the reasons I chose primary care. And most specialists are not egregiously forgetting their own responsibilities. But as it gets harder and harder to navigate the insurance traps and pharmacy coverage nightmares, as specialists accounts receivables fall and they try to increase their patient load to keep up (PCP’s gave up on that a long time ago, we just decided to become employed in droves), it gets easier to tell the patient to call me with the expectation that I’ll take care of it.

“The good physician treats the disease; the great physician treats the patient who has the disease.” William Osler. I would add to that “The good physician sends written communication to colleagues. The great physician picks up the phone to communicate with colleagues.”

OH, and while I’m on the subject of phone communication–does ANY specialist out there remember the common courtesy rules of making phone calls? If YOU want to talk to me, then YOU call me. You do not have your nurse call me and leave me sitting on the phone fuming while I await your presence. Why in the world do you think your time is more important than mine? I mean besides the fact that you get paid thousands of dollars more than I do. Your mother would be ashamed!

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