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, 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.

On interdisciplinary patient care and the corporate takeover of health care

The following is a gues post by Seiji Yamada, MD, MPH

In July 2015, on the 50th anniversary of the founding of the University of Hawaiʻi John A. Burns School of Medicine, the school invited its alumni for a Saturday morning symposium on "Transformative Medical Education in Hawai`i."  The last panel of the morning, on the future of medical education in Hawaiʻi, featured the deans of medicine, nursing, social work, and the associate director of public health.

Dr. Peter Donnelly - Kanaka Maoli family physician, practicing on the Neighbor Islands, my mentor in Hawaiian Pidgin and how to be local (I fail abjectly on both counts) - asked what the panelists think of nurse practitioners telling him that they can do anything he can do, at less cost.  One panelist suggested, "If you can't beat them, join them," so you might as well go get your MBA.

The claim that a non-physician provider can do the work of a physician at less cost ignores (perhaps willingly) the distinction between earning less and costing less.  Certainly non-physician providers earn less than physicians.  Dr. Stephen Kemble - psychiatrist and a stalwart for single-payer, who had been decrying the business takeover of health care from the audience all morning - noted that with regards to the provision of mental health, the evidence shows that non-physician therapists can actually cost the mental health system more than psychiatrists.  (He was citing an unpublished study performed by a Hawaiʻi health insurance outfit.)

Of note, a study in the September 2015 issue of Medical Care found that diabetic patients cared for by nurse practitioners had comparable rates of  preventable admissions as primary care physicians. The provider who cares enough to invest the time to talk with and assess the patient may also decide upon less intensive courses of care. The medical profession as a whole must shoulder part of the blame for the present situation.  Specialty control over the reimbursement system results, naturally, in disproportionately higher reimbursement for procedures and disproportionately lower reimbursement for primary care. See Outing the RUC: Medicare reimbursement and Primary Care. [1] This ensures that most medical students will choose specialty training so that there are not enough primary care physicians to care for all of us.  To the extent that physicians obtain MBAs and figure out how to game the extant reimbursement system [e.g. hire an N.P. to consult on patients so the gastroenterologist can perform colonoscopies in the surgicenter (anus to anus time of under 10 minutes) all day] - the proceduralist specialties are complicit.  Indeed, there is no reason why the gastroenterologist should explain the risks, benefits, and the bowel prep for screening colonoscopies.

We family physicians learn during residency that the practice of primary care is, in many ways more complex than specialty practice. [2] A well-trained, experienced provider of any discipline can deal with many complex patient problems for which a less intensively-trained, less experienced provider may order unnecessary tests or referrals.  Thus, while a primary care physician may earn more than a non-physician provider, the cost to the health care system may be less.

In addition, the provider who cares enough to invest the time to talk with and assess the patient may also decide upon less intensive courses of care.  These days, you can be largely assured that if you presents to the ED with a headache, you’re going to get a CT scan of your head.  If you present with abdominal pain, you’re going to get a CT of your abdomen.  Many patients with symptoms clearly suggested of reflux are kept in the hospital for observation to “rule out myocardial infarction.”  So, conversely, while a primary care physician may earn less than an emergency physician, the cost to the health care system may also be less.

While part of the problem may be that the nursing profession is eager to escape the yoke long placed upon it by the medical profession - perhaps the larger problem is what Dr. Kemble identified as the incursion of the business model into health care.

The business model is predicated on delivering a standardized product with quality controls on what can be measured at prices that the market will bear.  Thus at any fast food franchise, one can reasonably expect a hamburger without too much E. coli in it, at the price listed behind the counter.  The MBAs who run our health care systems have no concept of the importance of, for example, a longitudinal patient-doctor relationship to health outcomes.  If they can replace an experienced primary care physician with a lower-paid "provider," it's better for the bottom line. 

We in family medicine should not be picking a fight with the nursing profession.  (For the sake of patient outcomes, I am happy to help nurse practitioners improve their practice, and I am happy to learn from them what they do best.)  I think that the main problem is the marketplace model of health care.  Capitalism has always depended on maintaining a certain percentage of unemployment in order to keep workers a little afraid of losing their jobs and therefore toeing the line.  The corporate takeover of health care means pitting the lowest rung of the physician class, the primary care physicians, against a growing workforce of providers with different qualifications eager to take their jobs.  From where I stand, I think that all health workers need to unite against that.

[1] Freeman J. Outing the RUC: Medicare reimbursement and Primary Care. http://medicinesocialjustice.blogspot.com/2011/02/outing-ruc-medicare-reimbursement-and.html

[2] Freeman J, Petterson S, Bazemore A. Accounting for Complexity: Aligning Current Payment Models with the Breadth of Care by Different Specialties. Am Fam Physician. 2014 Dec 1;90(11):790. http://www.aafp.org/afp/2014/1201/p790.html

The Education of Health Professionals and Prospects for Transformation

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This is a guest blog post by Seiji Yamada, MD, University of Hawaii.

The Commission on the Education of Health Professionals for the 21st Century, chaired by Julio Frenk (Dean of the Harvard School of Public Health) and Lincoln Chen (President of the China Medical Board), published its report in the December 4, 2010 issue of the Lancet. Titled “Health professionals for a new century: transforming education to strengthen health systems in an interdependent world,” the report was released in the centennial year of the Flexner Report of 1910. In contrast to the Flexner Report, however, the current report broadens its focus from medicine alone to include nursing and public health education. In addition, instead of focusing on the U.S., the report takes global health to be within its purview.

As noted by Richard Horton, the editor of the Lancet, "A strong case is made that the present content, organisation, and delivery of health professionals' education have failed to serve the needs and interests of patients and populations."

The commission reviews a century of reforms in health professional education, identifying the Flexner Report as a key document of the first generation. The Flexner report is widely credited with placing American medical education on a scientific basis and leading to the closure of institutions that did not meet its standards. (A critical view of the Flexner Report, that it was a means for allopathic medicine to enhance its dominance over competing philosophies of health and healing might be gleaned from Paul Starr’s The Social Transformation of American Medicine.)

The Commission associates the second generation of reforms with the “instructional breakthroughs” of problem-based learning (PBL) and disciplinarily integrated curricula. Identifying McMaster University as its pioneer, the key aspects of PBL are identified as its learner-centered philosophy and small groups. Newcastle and Case Western are identified as the pioneers of disciplinarily integrated curricula. Other second generation instructional innovations include the use of standardized patients, a focus on the patient-doctor relationship, earlier introduction to patients, and expanding clinical sites to include community settings. (p. 1932)

My own medical school experience (University of Illinois at Chicago, 1983-1987) was singularly uninspired and had none of these elements. I’m assuming (hoping) that UIC is doing better now. It was not until residency (family practice at Cook County Hospital, where Josh Freeman was one of my teachers) that I was introduced to training in the community setting (the South Lawndale Health Center). But it does make me wonder to what extent these “second generation” reforms have been instituted in U.S. medical schools.

I was introduced to PBL (as well as disciplinary integration, discussions about the patient-doctor relationship in the family medicine clerkship, clinical experiences for MS1s, and student rotations in community health centers) when I joined the faculty of the University of Hawaii John A. Burns School of Medicine (UH JABSOM). Initially skeptical, I have become a proselytizer for PBL in a way that only a former unbeliever can be. (My friend Mark Durand prefers to say that he once was a sinner, now he’s a preacher.)

I do know that PBL has become the organizing principle of medical education in only ten or so U.S. medical schools. The institutional barriers to changing over an entire curriculum to PBL are significant. Basic science departments generally have to give up ownership of courses, as disciplinary integration is inherent to PBL. In addition, the faculty resources for conducting small group tutorials are significant. PBL fails without faculty enthusiastic about serving as tutors.

The Commission calls for a third generation of educational reforms. They call for health professional education that is patient-centered and population-centered. By “population” is meant the global population. The goal is that all people around the world have access to health care. “The ultimate purpose is to assure universal coverage of the high-quality comprehensive services that are essential to advance opportunity for health equity within and between countries.” (p. 1924)

This point is what makes this report of interest for the readers of Medicine and Social Justice. Our educational system is charged with creating the next generation of workers who will transform the health care system into one that will serve all of humanity. This cannot be achieved without inculcating an ethic of social justice.

The Commission calls for two educational outcomes in this third generation of reforms: transformative learning and interdependence in education. “Transformative learning is the proposed outcome of instructional reforms; interdependence in education should result from institutional reforms.” (p. 1924) Generally, we tend to view our role as educators as informative and formative: we transmit knowledge to our learners (inform) and place them in settings to develop professional attitudes (form), so that they become competent and eligible for licensure. However, if we expect the next generation to lead the reform of the health system so that it delivers health for all, then we must train them to become agents of change, that is, we must inculcate transformative learning.

The second outcome called for by the Commission, interdependence in education, reflects the need for teamwork in the delivery of all health services. Disciplinary boundaries among the health professions can be overcome by interprofessional and transprofessional educational models. [The Commission defines interprofessional as teamwork with other health professional students and transprofessional as teamwork with "basic and ancillary health workers, administrators and managers, policy makers, and leaders of the local community" (pp. 1943-1944).] This will require integration of institutions as well as disciplines. Curricula will need to take more advantage of global flows of information and educational resources.

The University of Hawaii made a foray into community-based interprofessional education in the early 1990s, when the schools of social work, nursing, public health, and medicine collaborated education at community health centers. Initially funded by the Kellogg Foundation, then by the Area Health Education Center (AHEC), this effort petered out after about ten years. With external funding running dry, the various schools involved failed to commit resources to the effort.

With regards to the transprofessional educational model - in a separate piece, Marshall MacLachlan of Trinity College, calls for integrative expertise in research and research training for global health. Noting that global health is a composite field, MacLachlan proposes “integrating research about ‘what’ (content), with research about ‘where’ (context) and ‘how’ (process).” (p.2) As an example, he offers “Paul Farmer’s work on HIV/AIDS (Content), his socio-political analysis of power relations (Context), and his service delivery role in Partners in Health (Process).” (p.3) Of course, Farmer is a neo-polymath (to use MacLachlan’s term), but MacLachlan’s point is that “these people tend to emerge individually, we don’t have an explicit way of producing or encouraging such skills, or encouraging a more integrative orientation in general; and we don’t have a structure for teaching it.” (p.3)

But the fact of the matter is that our learners are demanding such teaching. As Skip Burkle points out (personal communication), young people and second career adults are demanding educational programs in humanitarian assistance. He notes that the majority of people responding to the Haiti earthquake were under thirty years old, and for many, it was their first experience in disaster assistance. Young people recognize that their working years will be spent in a globalized world, and that much of the world is characterized by poor governance and poor social and physical protections. Burkle, Clarke, and VanRooyen point out that humanitarian community inadequately translates humanitarian action into public policy. Young people recognize that they will also need to lead at the policy level.

At UH JABSOM, students formed their own organizations, the Global Health Interest Group (GHIG) and the Partnership for Social Justice (PSJ). Students in the PSJ are organizing their own leadership workshop to learn about how to improve the health system. They are motivated by a moral belief in health as a human right and the need for more social justice in health and medicine. The tasks in store for us as teachers are self-evident. Our students are demonstrating their commitment to globalism, to social justice, and to a conception of health that transcends narrow disciplines. We need to make sure that we can help prepare them to achieve these goals.
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