Monday, September 25, 2017

How to prescribe a glucometer – or why I can’t support Medicaid-for-All

This is a guest post by Seiji Yamada, MD, MPH.
A shorter version recently appeared on the KevinMD blog,

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 (, 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.

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