Physician Frustrated in Efforts to Prescribe Critically Necessary Medications

In today's post, our guest blogger, a local primary care physician, sounds off on a bureaucratic nightmare and the potential harm to patients:

I am a primary care physician and have been practicing in Cambridge for nineteen years. There are many challenges and frustrations for physicians attempting to provide the best possible and safest office based care to patients. However, never before have I felt more outraged by the unnecessary potential and actual harm and suffering some of my patients have had to endure with the introduction of many of the individual insurance programs that were created by the relatively new Medicare Part D program. Some of these programs are completely unscrupulous in their limitations to essential medication.

Here is one example:
One 63 year old man who has multiple medical problems including diabetes, hypertension, heart disease and decreased kidney function has been fairly stable in recent years, but close to needing dialysis in spite of our best efforts to hold that off with medications. There are many clinical guidelines and studies that support the use of one of his medications (losartan, of the class of medications called “ARB’s) to protect his kidneys and stave off dialysis in the situation he is in (He is unable to tolerate first line medications called “ACE I”). He had been on this pill along with many others for many years. When his insurance was switched to Health Net Orange, one of the 15 or so Medicare part D programs approved to practice in the state, they denied him use of this medication or any alternative in the class. They offered no explanation except to say that it is not formulary. After reapplying a couple of more times and being rejected I called the company myself, hoping to reach a medical reviewer, even the Medical director to explain my rationale for the necessity of this medication. After literally 2 hours of calling, getting put on hold and being transferred, this physician had only spoken to various clerks, and gotten no useful advice. Further calls by the office manager were equally unfruitful. Finally the only way the medication was approved was when I referenced in my clinical notes that I felt that this medication was necessary to prevent complete renal failure which would lead to lifelong dialysis, stroke or heart attack, and that in spite of my best efforts to get the medication approved, his insurer would not do so. I further went on to say in the record that I felt the insurance company should have some responsibility if one of these untoward events occurred while off his medication! I have never written anything referencing any insurance company in a record in my entire career, and might have considered it unprofessional before this, but my patient’s health was at stake and I couldn’t think of any other way to try to get the medication approved.

I sent a copy of this note to the insurance company with the fourth medication request and after about 6 person-hours over a 3 week period of time trying to get this medication approved, it was miraculously approved the very next morning until the year 2039!!

It infuriates me to see patients put at unnecessary risk like this, and it is exhausting the precious resources of primary care practices. Think of the cost of this occurring dozens or hundreds of times per year probably in every office in the state and the harm that undoubtedly has come to easily thousands of patients per year! This is not the only insurance carrier that commits this disservice; but some the Medicare part D carriers are very much more inclined to this sort of practice than the HMO’s and traditional carriers in the area and even much more so than Medicaid and the newcomer Commonwealth Care, in my experience. I write this to help give a voice to practitioners struggling to do their best for their patients in this arena and to let patients know about this threat to the safety of patients that is very real and has disempowered practitioners to get their patients medications they need. I am looking for ideas how to find ways to make these carriers more accountable to patients in the basic area of necessary medications.

THE POWER OF A PERSONAL/PROFESSIONAL STORY

Over the past six years on behalf of MITSS, I have had the great fortune of travelling the country and abroad. I have spoken at conferences and forums, large and small, speaking with patients, family members, and clinicians. It seems that everyone has a story. Each time I speak with a clinician who has been affected by a medically induced trauma, I not only relate on a truly personal level, but it has served to strengthen my commitment and resolve to change the systems which fail each of us every day.

There can be nothing more powerful than a personal story, and we have encouraged anyone affected by an adverse event to share their experience with us on our website. While it seems that I hear from healthcare providers in equal numbers, they don’t appear as willing to share their stories. There has been a very moving entry recently added, and we invite you to take a look at our clinician story page. Also, if you’d like to share your own story, please feel free. The submission is anonymous, and confidentiality is assured. By sharing your personal and professional experience, you may be helping a colleague out there to feel less isolated and alone. We hope to hear from you.

Linda

Communication Loop Following Adverse Events

Below is a Post I wrote last week but we held off posting it....



All the literature out there tell us that patients and families want several things following bad outcomes and medical errors:

1. They want the truth and in a timely manner.

2. They want either an apology or an acknowledgement.

3. They want to know what the organization is going to do to prevent another occurrence.

4. They want support.

a. emotional support
b. financial support when appropriate

My observation, though, is that many hospitals still struggle with looping back to the patient and family with the information about what happened and how. But, more importantly, they neglect to relay to patients and families the changes to be made moving forward to prevent reoccurrence.


There isn't a mechanism to loop back to staff to give them the same information. I can see why this would be difficult given all the different departments and staff involved. But, I think it just as important that we be transparent with the staff as well. It would also diminish assumptions and rumors among staff.

Does anyone have ideas for how this can be done effectively and routinely?

Does anyone have any suggestions on how we can start doing this better?

...this post seems fitting given the news last week of a Boston Hospital that had done a wrong site surgery. They disclosed to the patient who is recovering at home. But, the President/CEO and the VP of Quality and Safety sent an internal email (click here for full text) letting the staff know about what they described as a horrific incident. I was truly impressed!



Linda Kenney
MITSS