Tuesday, November 03, 2009

When Hoop-Jumping Becomes Patient Care

"Doc, I've got good news and bad news."

"What's that?"

"Well, I've lost six more pounds!"

"Wonderful! What's the bad news?"

"Well, you know that new-fangled drug you gave me that works so well for my atrial fibrillation?"


"We'll, I'm part of that AARP Medicare Advantage Part D drug plan, and I just got the "partial" approved drug list for 2010 in the mail. My drug's not on the list, so I called and found the drug's been moved from a Tier II drug to a Tier III drug. That means it will cost me twice what I paid for it this year. That's gonna be tough, doc. I can't afford it.

But I also read that if you call this '800' number and speak to them, they'll allow me to obtain an exemption to keep the drug on Tier II for next year."

I called the number as I typed his note. The patient seemed pleased that I'd be so attentive to his needs during their office visit. A sophisticated voice-recognition triage prompt answered:
"If you're calling about an injectable insulin question, say 'insulin,' drug issue say, 'drug,' if not part of this list, say 'other,'..."
"Drug," I said. a brief pause occurred, then:
"Just a moment..." (Soft music played in the background.)
Finally, a woman answered. he was quite pleasant as I explained the situation. Finally, I got to the part about the patient's drug not being on the 2010 drug list.

"Oh, 2010?" she asked.

"Just a moment."

On hold again. We continued our office visit. "So, how often are you having those episodes of..."

"Dr. Fisher?"


"What other drugs has the patient failed?"

We listed them: "Atenolol, Sotalol, Amiodarone..."

"And when were those drugs used?"

"Um, seriously?"

"Yes, I need dates."

"Well, according to the fancy-schmancy electronic record, he's been on this Wonder Drug since November 12, 2007... his Amiodarone was stopped then."

"But the other drugs, when were they started and stopped."

I made up some dates. I was not about to spend time culling the record for these dates, but it was clear that data entry fields were being placed on the opposite phone line. I suggested to my patient he write down those dates.

"And why was the Amiodarone stopped?"

I looked at my patient. He quickly reminded me about the lung findings and liver toxicity he had experienced. I spewed the information to the inquisitor in hopes of expediting the interview. It was taking entirely too long. I looked at my patient. This would be his visit. His priorities were set: money talks after all. So I continued. After submitting the answers, she responded:

"Just a moment while I give this information to my supervisor."

Soft music played again. I looked up at my patient. "Um, where were we? Oh, yes, how often have you been..."

"Dr. Fisher?"

"I've given the information to my supervisor."

"Okay, will he receive his Tier exemption?"

"Oh, we've not received the final list yet for 2010."

"But my patient called and discovered this drug was moved from Tier II to Tier III. Why does he know the information and you seem puzzled by the list?"

"As I said, we're still waiting for the final list..."

It was obvious that the discussion was going nowhere.

"So how will Mr. Smith know if he's been granted the exception?"

"My supervisor will review the application for the Tier review and make a decision. Is there anything else you need?"

Realizing that there was no way I was going to get an answer, I acquiesced. "No, I think we've handled the application. Thanks for all you help. By the way, in case my patient would like to check on the application, what's your name?"


"Thanks, Christine. And your last name?"

"It's just Christine."

"Uh, okay. And how about your supervisor's name?"


"Jericho who?"

"There's only one Jericho here," she said.

I could only think one thing at that point as I hung up:

... I bet he's a "wall."



An oncologist said...

Ahhh, the insurance companies playing doctor. Two years ago, I diagnosed a patient with CML. I wrote for Gleevec, a now not-so new targeted drug that has an incredible response rate for CML(it's the molecularly targeted drug for CML). Insurance company refused to cover it for this 70 year old with multiple co-morbidities because I hadn't given her interferon (that's a WTF moment; she would never tolerate IFN). We spent hours petitioning this thing. In the process, I had to sign a form that stated I would not be submitting a bill for my time spent as a physician advocate. As with your experience, I could never get a last name. I demanded to speak to the medical director, but....he doesn't have a phone!

I learned that there is some mumbo-jumbo legaleze in Medicare D allowing these companies 6 weeks to consider approval or disapproval of drugs. At almost 6 weeks to the hour after the initial submission, her Gleevec was approved. In the mean time the family was panicking because their mother's leukemia was not being treated.

The company saved 6 weeks of not paying for the drug. You add up enough of those delays, and they save money.

#1 Dinosaur said...

You've just re-written a version of Chapter 3 of my book. (Third Law of the Dinosaur: The urgency of the test is inversely proportional to the IQ of the insurance company preauthorization clerk.)

DrV said...

This is an everyday event in my world of PPIs. I've reached a point where I have effectively given up.

Anonymous said...

Wow, that sounds alot like Medco, Aetna and Express Scripts. I've come to the conclusion they are all the same company. I've spent more time answering stupid questions like that for our patients, too. Our biggest problem is trying to get BRAND name meds for patients who have had severe reactions to the generic. It's rare, but it happens. :D

Hospitalist said...

I often wonder why we (doctors) put up with this--but it now occurs to me--why do patients put up with it? It was good that you did this in front of the patient. Perhaps more of us should do that so that patients understand all of the hoops we have to jump through.

Anonymous said...

@Hospitalist and Dr. Wes: As a patient, not a healthcare provider, I understand some of the hoops you jump through. I get the sense that you understand some of the hoops we patients jump through too. I don't know what the big answers are to crap like this, but I *do* know that, reading your blog has made me far more reluctant to say/tell/ask my physician anything. So, unlike the patient in this hypothetical post, who shared his/her clinical successes and bureaucratic frustrations, I won't ask you or my PCP to go through these hoops. I have enough problems without being the source of your problems too. Feel free to use those 4-7 minutes you would have scheduled me for something else. I won't bother you again. (Is that your intent, because that is indeed my conclusion after reading MD blogs: dealing with me and the inevitable insurance folderol--which by the way, I didn't create-- is a gigantic bother, and life as a physician would just be so much better if you didn't have to deal with patients and their needs).

DrWes said...

anony 04:00PM-

Your point is exactly my point in bringing this to the attention of bureaucrats everywhere: imposing more administrative hoops (be they pay-for-performance, med authorizations, insurance pre-approvals, etc) does nothing to improve patient care and only serves to alienate the doctor/patient relationship. Rest assured all doctors would much rather deal with patients than these issues.

Anonymous said...

Bureaucrats have one dimensional
minds. They are both unable and unwilling to use reason. If they are told something they don't understand they automatically eject
it and a blue screen appears in their minds automatically shuting
the whole process down. The are
programmed not to listen, only to
follow established proceedure as
indoctrinated. Healthcare personnel
are always in a hurry and under pressure. The combination of these
two problems automatically causes
problems and mistakes and the patient is often comprimised as a
result. In order to survive a patient must take as much control as is possible or become a victim.