This is a guest
post by Seiji Yamada, MD, MPH.
A shorter version
recently appeared on the KevinMD blog, http://www.kevinmd.com/blog/2017/09/heres-glucometer-turned-doctor-medicaid.html
In a recent Vox
interview, Senator Brian Schatz of Hawaii announced his plans to sponsor a
bill to allow individuals without insurance to buy Medicaid coverage for
themselves. As a family doc who cares for patients on Medicaid in safety
net clinics in Senator Schatz’s home state, I cannot support such a plan.
While private insurance companies
offer supplemental insurance, Medicare continues to be run largely by the
federal government. In contrast, while Medicaid programs receive federal
funding, they are largely run by state governments. In a trend known as
Medicaid managed care, in recent decades, states have been contracting out
Medicaid to private insurance companies.
Prior to 1994, Hawaii’s state
Medicaid system was run by HMSA, Hawaii’s Blue Cross/Blue Shield. During
the Clinton presidency, the buzzword was managed competition, the idea being
that insurance corporations would compete on price to provide publicly funded
health insurance. Thus in 1994, the State of Hawaii devolved to managed
care Medicaid and started farming out Medicaid to other corporations besides
HMSA. In 2009 Medicaid managed care was extended to the aged, blind, and
disabled.
Medicaid also generally reimburses
at lower rates than Medicare or private insurance. (Senator Schatz
proposes to fix this.) However, low reimbursement is only one reason that
physicians in private or group practice take few Medicaid patients today.
Another reason is the administrative hassles to care put up by insurance
companies as well as the difficulties of dealing with multiple insurance
companies. Thus, Medicaid patients have relatively restricted networks of
providers from which to choose. Many are therefore seen by safety net
providers such as Federally Qualified Health Centers (FQHCs) or training
clinics.
The modern practice of medicine is
complicated enough, but the different requirements and different formularies of
different insurance companies complicates it to Kafkaesque levels. I
believe that the powerlessness and helplessness induced by this nightmarish
bureaucracy is a major cause of physician burnout. I want to give just
one example. Let us say that one of our patients has newly diagnosed
diabetes. Let us say that he has Medicaid. Just to prescribe him a
glucometer, I have to go through the following:
Patients on Medicaid must enroll
with one of the following: HMSA, AlohaCare, Ohana (WellCare), United
Healthcare, and Kaiser. I need to go to the insurance section of the
patient’s Electronic Health Record (EHR) to find out which insurance corporation
is responsible for this patient. Then I go to The Prescribing Guide (http://prescribingguide.com/), a cheat
sheet developed and maintained by my family medicine faculty colleague
Chien-Wen Tseng, MD. The prescribing guide tells me which brand of
glucometer to prescribe.
Each insurer contracts with a
different glucometer manufacturer, so I can’t just prescribe a generic
glucometer. I have to figure out whether to prescribe Freestyle, or
OneTouch, or AccuChek. Because the contracts are continually
re-negotiated, the preferred brand can change every six months. If you
enter the wrong brand, the pharmacy will reject it and tell you to get a prior
authorization.
Next, I have to identify the ICD-10
code that corresponds to the highest complexity of the patient’s
diabetes. Does she have nephropathy, or neuropathy, or
ophthalmopathy? I often have to review the patient’s labs to see if the
creatinine/GFR is abnormal. Am I going to place the patient on long-term
insulin? Because if I am, I can justify asking for test strips for more
than once a day testing. The number of times per day the glucose is to be
measured, the ICD-10 code, and whether or not the patient is on insulin has to
be on the prescription. If not, the pharmacy will reject it.
Now that I have prescribed a
glucometer, I can now start working on prescribing a diabetes medication.
And I’ve yet to address the
fatigue, the blood pressure, or the back pain for which his friend’s oxycodone
worked real good, Doc.
. . .
“All the world's a stage,
And all the men and women merely players” -Shakespeare
Was this theater of the absurd
composed by Alfred Jarry? Samuel Beckett? No, this play was
composed by the layers of business administration types that have piled onto
the health care system over the past couple of decades to bring corporate-style
efficiency to medicine. Insurance companies limit their costs by imposing
roadblocks. By making it so time-consuming and so frustrating to get
anything done, we physicians throw up our hands and decide, no it’s not worth
the hassle to order a different medication or sophisticated tests.
Perhaps my patient gaining weight on a sulfonylurea would benefit from a glucagon-like
peptide 1 receptor agonists or a sodium glucose transporter 2 inhibitors
instead. But the prior authorization form requires me to list the dates
that the patient has taken every other diabetes medication she has ever been
prescribed . . .
For those physicians who are
employed by hospitals or other institutions, we are finding that our employers
are engaging in an arms race with the insurers by hiring their own army of
coders and billers. These coders and billers find our documentation
lacking in order to maximize return. So now we are told to write addenda
to chart notes entered months ago - in order to justify higher
reimbursement. These coders and billers shake their heads sadly and say
to themselves, “Dr. Yamada, you are such an idiot.”
. . .
The new interns started in
July. When they were medical students, I taught them about the
pathophysiology of diabetes, about the evidence base of what treatments have
been shown to improve patient outcomes, about how to discuss lifestyle
measures, about the social determinants of the development of diabetes.
Now that they’re interns, though – all of that goes out the window. Now
that they’re managing real patients, I teach them how to enter billing codes
into the electronic health record, and how to get a glucometer covered by
insurance.
They look at me with
incredulity. They are dumfounded by how irrational and Byzantine our
health system is. They realize that I am no longer teaching them
medicine. Because there is no time for that now. There is only throughput.
Treat ‘em and street ‘em.
“Welcome to the desert of the
real,” I say. “Get used to it.”
. . .
The MBAs who manage us physicians
say, “It’s not about throughput. It’s about quality. We’re not
going to pay you for throughput any more. We’re going to pay for
performance. We don’t care how many times you see the patient. We
only care about their A1cs.”
OK, then, tell me how you get
better outcomes with a patient with diabetes without seeing them every once to
talk with the patient about diet and exercise, to prescribe a glucometer so
they can learn how diet and exercise affects their glucoses. What is the
point of telling the homeless patient to bring down their A1cs by eating more
fresh vegetables? What use is the A1c when the patient has cancer?
What does the patient dealing with domestic violence care about her A1c?
To measure the quality of care provided by a physician through A1cs is like the
drunkard searching for his keys under the streetlight because that’s where the
light is. The A1c is easily measured. Other aspects of medical care
are not so easily assessed.
. . .
Insurance companies and their
corporate mind-set have so thoroughly taken over American medicine that we can
hardly see the forest for the trees any more. EHRs, essentially designed
for reimbursement purposes, define the patient encounter – such that physicians
look only at their screens. I can’t afford to make eye contact with my
patients, or I’ll fall hopelessly behind. Was there a time that we used
to eat lunch? Nowadays, lunchtime is for finishing with charting or
dealing with phone calls. Dealing with medication refills, or lab or
x-ray results? Planning for the patients on tomorrow’s schedule? We
do that in the evenings or weekends by remote access to the electronic health
record.
Though Senator Schatz’s proposal
would make Medicaid something like the public option that didn’t make it into
the Affordable Care Act, it would likely leave intact insurance company-run
Medicaid managed care – with its restricted networks and administrative
hassles. As a practicing physician, I would like to get corporate profits
and the layers upon layers of bureaucrats out of medicine. The American
physician is in a predicament like that of Josef K in Kafka’s The Trial.
The rules are obscure and seem to be constantly changing. We are never
told what crime we committed to justify our being treated the way we are.
The sense of a lack of agency and helplessness induced is one major cause of
physician burnout. The practice of American medicine needs to be
rationalized, so that we health workers can go back to focusing on the
medicine. Medicare for All is what we need. Not all the
inefficiencies and irrationalities of the modern practice of medicine will be
fixed by Medicare for All – but patients and doctors need a way out of this
Kafka novel.
