MAYBE IT'S A GOOD THING I wasn't top of my class in medical school. Then I might be even more aggravated by the insurance companies' pre-authorization regulations telling me what I can and can't do--regulations that are liable to push some of our patients over the edge, causing them to go "postal" on us.
Medical school was the hallowed halls of Guy's Hospital in the borough of London Bridge. A somber, ominous place where students were derided by sarcastic attendings and disparaged by fussy matrons in silver buckles, silly hats and starched lace. A place where I lurked in the background and didn't exactly shine, but where I did manage to get a medical degree.
Since then, I have kept up my continuing medical education, sat and passed the Boards every seven years, and developed this outrageous notion that I know a little bit about what I'm doing and how to treat my patients.
Wrong.
Wrong at least in the eyes of the insurance companies, or so it would seem. In this day and age, some insurance company policymaker
Some bean counter reviewer decides if Mr. X's back pain is bad enough that he can get one of those awfully expensive MRI scans. I am gratified and humbled to know that they do at least read my notes. But if they don't think it's necessary--even if I , in my educated wisdom, think it is--well, too bad for the patient.
In the old days, when my great-grandfather was a general practitioner in Ballaratt on the outskirts of Melbourne during the Australian gold rush, he would treat a colorful variety of diseases in the surgery room attached to his house. Or he'd go off for days at a time in his horse and buggy into the bush. He didn't always get paid, or sometimes it was with a chicken or some other kind of barter, but there was no one interposed into that intimate relationship between doctor and patient.
How progress has changed all that.
From a mechanism for taking some of the gamble out of health-care costs and preventing bankruptcy during major illnesses, the insurance companies have grown into something like willful children. They bully and intimidate us into keeping expenses low--so they can make huge profits.
The Mary Washington Hospital library staff helped me with a little research, finding that Aetna's revenue rose 14 percent to nearly $6 billion this year, according to SmartMoney.com. Meanwhile, United Health Group's profits rose from $37 billion to $45 billion between 2004 and 2005, according to the group.
Piggy in the middleI sympathize with my patients at what their insurance costs (and with myself for what mine costs). And I firmly believe that health care is a fundamental right that should not be left to the caprices of big business to profit from.
But to add insult to injury, we doctors have to deal with the wrath of the patients getting all bent out of shape because we haven't done whatever needs to be done to pre-authorize their particular medicine--for which they hold us personally responsible.
I had a very lively consultation with a patient recently who came exclusively to haul me over the coals because it had taken a year to get her particular antidepressant pre-authorized. The cause: a series of misunderstandings, lost faxes and other pitfalls that plague the whole process. (Meanwhile, we supplied her with lots of samples, and she went off medication for a while, which must have saved the insurance company a tidy sum).
We have other patients--some with a history of violence--calling us up and telling us they're "coming in." My staff is advising me to get over my prejudice against guns and start packing.
A circumstance that ratchets up the pressure is a kind of battle of the leviathans. Drug companies--the other big moneymakers in the health-care industry--can and do advertise directly to the public (in contrast to England, where it is illegal). They push their latest, most expensive drugs--Ambient CR, Sporonox--so all our media-attentive folks, being the good consumers that they are, come and want those medicines.
Then, when those medicines aren't on the "preferred" list of their insurance, they are mightily put out. We, the doctors, are the "piggy in the middle."
A bad jokeEven medicines that are not so new are hard to get if they're not on the preferred list. Yet it seems the insurance companies often blithely tell the patients "just have your doctor call us." It's a bad joke. We're transferred around a massive phone tree, listening to countless messages of how "your call is very important to us," and never get to anyone who has the authority to give a "yes."
Another slightly spurious spin off this whole "preferred medicines" business is that the drug reps now use this as a major selling point. The "ARB Wars,"
There's a rapidly escalating competition between the different companies over these drugs. The promotion hinges not on the merits of the medicines, as you might naively think, but on whose product is on the preferred list with which insurance companies.
"Look, Diovan has much better coverage than it's competitors," the Novartis rep tells me. Then the Cozaar, Micardis, Benicar and Avapro reps all come and tell me the same thing about their ARB product.
What to do about it is the question. I am in favor of a revolution. I think all the doctors should band together and "just say no." But getting doctors, known for their willful independence, to cooperate and follow a specific unified strategy is pretty much like herding cats.
The logical solution is for the patient to drop that insurance if it's so darned persnickety, but we all know that precious few people have a personal choice. One usually has to go with whatever company one's employer finds most attractive (which usually means cheapest).
So I guess I'll just have to accept the wrath of the patients who can't get their medicines, and the aggravation of the bean counters overriding my good judgment.
What's that in the Serenity Prayer about "accepting the things I cannot change?"
DR. PATRICK NEUSTATTER can be reached at
Email: pneustatter@prattmed.com.