Merry Christmas From Your PBM

 

After some deliberation I went into my local Walgreens for an RSV immunization.  I have multiple unpredictable allergies and have had both anaphylaxis and significant local reactions to vaccinations in the past. Like 20% of the population, I have eczema and there is some research on flareups of this skin disease with vaccinations.  And like many people with eczema, I also have asthma and had a severe flare-up of asthma when I got a viral infection on a flight back from Alaska about 5 years ago. My primary care physician recommended it last week so I scheduled it.

As I was sitting there waiting for them to prepare the shot, I was able to observe patients coming and going to pick up their prescriptions. This is a busy Walgreens and there are people going past the drive-up window as fast as they are showing up in line.  Most people at there in the early afternoon are retirees.  There was an informal retirement poll of the old guys in line and it was unanimous – we were all quite happy to be retired. The people gathered were upbeat. I recalled being at a 24-hour pharmacy in 2002.  My late father-in-law was visiting and forgot all his cardiac medications.  I went over at midnight to pick them up and it was an ugly scene.  There were about 60 people there and the pharmacist was not filling the prescriptions fast enough. From where I was seated – I could see him working furiously.  The crowd was so agitated about this it seemed like they were ready to riot. If that wasn’t enough a rather cranky lady sitting next to me started to goad them and call them names.  Luckily, I got the medicine and got out of there as soon as possible.

 The atmosphere today was much better – but like most scenes in American health care it was far from perfect.  There were no simple transactions. In the transactions I witnessed, very few people walked away with the prescription medication ordered by their doctors. The most common problem as a lack of prior authorization. People were advised that their doctor had to get the prior authorization. Several were advised that they needed a new prior authorization. I remember all the messaging that people hear when they need a prescription refill.  Call your doctor’s office.  Don’t call your doctor’s office.  Call the pharmacy.  Don’t call the pharmacy.  Today 75% of that messaging was incorrect.  And it wasn’t like the medications were an option.  Antihypertensives, diabetes medications, prostatic hypertrophy medications – every medication name I heard had me hoping these impasses would be resolved as soon as possible for the patient’s sake. The related quality issue is that most of these medications were maintenance medications and yet they required reauthorization – in some cases just because of an insurance change.  I didn’t see anyone get hit with the Medicare Donut Hole. I have been twice in the past 3 months with a copay for apixaban ballooning up to $400 or roughly 7 times the usual amount just because of the way the rules are written to favor pharmaceutical companies and pharmacy benefit managers (PBMs). I am sure it would have happened if I had been there longer.

But 20 minutes was up and I did not have an anaphylactic reaction. Another immunization I can take.  I jumped in my car, turned the radio on, and thought about what I had just witnessed.  I am certainly no stranger to it. As a physician I have been harassed by PBMs.  They put me on hold for hours only to eventually connect me with a clerk with no medical training or credentials that would either approve or reject my recommended prescription.  PBMs are not some quality improvement project – they are patient and physician harassment to see who blinks first and loses the time and money.  They are multibillion dollar companies that add to the cost of medications rather than reducing the cost.

Overall prescription drug pricing in the United States is much higher than in comparable countries both on an overall basis and a brand name basis.  A study (1) that looked at 2018 data showed that all drug pricing ranged average 258% higher than comparable drugs purchased in Mexico, Canada, France, Germany, Italy, Japan and the UK.  Comparable brand name medications averaged 344% higher.  All of that translates to much larger copays for Americans and often an inability to purchase the medication. I saw that happening a lot today.

Advocacy from the physician side has been weak. After decades of no action on the prior authorization issue some professional organizations are now saying that it needs to be controlled. The problem with that position is that it is so ratchetted down on patients and physicians that any controls in the right direction will be trivial.  The only solution is to eliminate prior authorization completely. If pharmaceutical companies want to deny payment for prescription medications – they can do it directly without using the physician and pharmacist for cover. Beyond that the appeal can go through a state administrative authority independent of the pharmacy business.

I have written extensively in the past about the sheer amount of resources that are wasted on prior authorization and the associated pharmacy rationing strategies.  I have written about how pharmacists take a significant hit and their professionalism is adversely affected by poor PBM reimbursement and conflict of interest – especially when the PBM owns their own chain of pharmacies. Today as I was waiting for clearance after an immunization it was all about the human cost.

That never seems to get better, although the Obama and Biden administrations have provided some significant relief to Medicare recipients. Everyone involved would be happier if this system was just gone.

 

George Dawson, MD, DFAPA

Supplementary 1:  Additional inefficiencies - a couple of days after writing this post my wife got a text message that one of her prescriptions was ready and she could "pick it up after Sunday."  She asked me to pick it up on Monday because I was driving by the pharmacy.  I pulled up to the window and asked for the prescription and was told - "it is ready but you are one day early.  You can pick it up tomorrow." Not the first time that has happened.  The pick up rule seems to vary by PBM, insurance, and pharmacy but the automatic messaging obviously does not take it into account. Just another reason for going to the pharmacy and leaving without the prescription. 

 

References:

1:  Mulcahy AW, Whaley C, Tebeka MG, Schwam D, Edenfield N, Becerra-Ornelas AU.   International Prescription Drug Price Comparisons Current Empirical Estimates and Comparisons with Previous Studies.  Rand Corporation Research Report. 2021.

2:  Yetter DM.  Reprieve for Kentucky’s independent pharmacies is saving Medicaid millions.  Kentucky Lantern. October 5, 2023.  https://kentuckylantern.com/2023/10/05/reprieve-for-kentuckys-independent-pharmacies-is-saving-medicaid-millions/

This is the story of how Kentucky eliminated PBMs in their state and saved $283M in three years. 

Graphic credit:

Me - my wife reshot the photo.

Another Bad Editorial Decision and more.....

I am on record recently pointing out how top medical journals have evolved to the point that they are posting a continuous stream of opinion pieces of variable quality.  It is not uncommon to find that from week to week diametrically opposed views on topics are published.  The most alarming trend in the posting of business views; usually along the lines that there needs to be continuous business reform in health care.  These are basically opinion pieces looking for a political foothold.  The precedent of course is managed care.  After it gained a political foot hold in the Clinton administration it became a business worth hundreds of billions of dollars.

In the case of managed care it was sold as widespread "reform".  After 30 years of managed care rationing the per capita health care costs in the USA are quite unbelievable when compared with even the next most expensive system ($9,086 in USA versus $6,325 in Switzerland).  The other top ten nations are seriously outdistanced.  Rather than acknowledge managed care as just another political flop there are endless editorials on how it really slows the growth of health care.  There are editorials of how it is really a success despite these outrageous numbers and nearly complete hegemony by managed care and insurance companies.  It is difficult to see how responsible editors of medical journals can continue to publish this pro-business propaganda.  They are certainly more circumspect about making these pages a sounding board for the pharmaceutical industry.

The largest divergence when it comes to health care costs is a managed care propensity for a disproportionate focus on mental health and psychiatric services.  This is nothing new.  It has been well documented since the  Hay Group found that from 1988 to 1997 that a total value of health care benefits for over 1,000 large U.S. employers declined by 10%.  Of the decline general health care benefits declined by 7%, but behavioral health benefits declined by 54%.  Behavioral health is managed care speak for mental health and psychiatric services.  Those same services dropped from 6% to 3% as a total percentage of health care costs.  While general medical services increased by 27% outpatient mental health services dropped by 25%.  Mental health benefits from employer based health insurance dropped by 50% between 1988 and 1998.  The true costs of managed care rationing have never been seriously examined.  There is an obvious conflict of interest when the government basically invents and industry based on a flawed political theory and the system floats based on these invented special interests.  

I did not really think that these opinion pages could be any worse until I happened to open up JAMA Psychiatry the other to do some reading while I ate my Wheaties.  I ran across an article called "What to do when your managed care firm says no."

The answer from my experience is nothing - you are basically out of luck.  In my experience managed care companies don't care if you live or die.  They don't care if you have the world's worst eating disorder.  They don't care if you have tried to kill yourself while intoxicated and your psychiatrist is saying that you will absolutely use alcohol, heroin, methamphetamine, dextromethorphan or any number of drugs immediately if you are not sent to treatment after acute stabilization.  They don't care if you need a longer period of time in the hospital.  They don't care if you have been committed for a suicide or homicide attempt.  I am not saying all of this just because it is true.  I am saying it to point out something that is often overlooked.  Why would a managed care company or MCO care?  They have never met you and have no personal responsibility to you.  As a business, especially in the new era of business management - they basically have a responsibility to make money for their shareholders.  The caring aspect of MCOs is really a public relations stunt.  They involve your doctor and make it seem like their decision - is your doctor's decision.   They waste your doctors time in order to make it seem like their refusal to pay for your care is somehow a conjoint decision with your doctor.

But back to the article.  Here we have a managed care insider giving advice to patients and physicians on how to deal with their denials.  I would consider this all tongue in cheek advice if it was not sitting right there in JAMA Psychiatry.  I will focus on a most familiar scenario denial of inpatient care.  This is a case of a hospitalization for schizophrenia where "the hospital tells the mother that it is time to discharge her son because the MBHO (Managed Behavioral Health Organization) says so and has an appointment for her son to be seen a month after discharge" (p. 1109).  The author suggests that in the case of this dispute the vendor will have a formal appeals process and that will include "a review by a psychiatrist not on the MBHO's payroll."  That has not been my experience.  The review is generally done by psychiatrists a long distance away.  They may not be licensed in the state where the patient is hospitalized.  The ones I have talked with are either openly hostile, pretending to be on your side, or clueless about the severity of inpatient problems.  Keep in mind that most psychiatrists do not practice in inpatient settings beyond their training years.  I have never seen a study that looked at whether these reviewers were actually treating very ill psychiatric inpatients - but from my conversations I think they were not.

The author goes on to say that the family can then apply to the employers benefits manager to apply leverage to the MBHO and have leverage in the case of inadequate care.  What is wrong with that picture?  For starters any sequence of events where clinical decisions are being made by business types is by definition - inadequate care.  Secondly, there is an inherent conflict of interest when your employer and an insurance company they are contracting with start negotiating your medical or psychiatric care.  Once again - neither of them has a responsibility to you for giving you the best possible medical advice.  They are giving you a business decision that saves them both money and calling it a medical decision.  The MBHO is protected against liability from that decision by federal law.  Your employer is protected by saying it was the decision of the MBHO and not them.  If you really think that your employer is interested in your personal health, go talk to the decision maker in person and note their level of interest.

The final vignette provided by the author is there to justify managed care.  It has been their war cry since day one and that is excessive utilization.  In this case we are lucky to have Big Brother watching in the case of psychotherapy delivered so inexpertly that the therapist states: "I am this patient's only friend so she needs to to keep seeing me."  This was after years of treatment.  I think that we can  all breathe a sigh of relief that an MBHO being paid millions plus incentives to ration psychiatric care can identify the worst therapist in the USA after years of therapy.  It is a miracle of modern management.

When you have editors who accept this level of an article it is a direct insult to anyone who has personally dealt with these companies and who knows what is going on.  It is a direct insult to the medical profession and physicians who have dedicated their lives to learning complex, highly technical profession to suggest that they should be clerical workers and work for free as employees of managed care companies.  It is an insult to desperate patients and their families who put up with all of paperwork, inefficient billing and arbitrary denials of care.

If the editors of medical journals are not bright enough to question the accuracy of a piece like this or they have not had the clinical experience of dealing with the constant harassment of managed care companies - they should defer the commentary section to somebody who knows what they are talking about.

Better yet - time for a moratorium on business and political commentary in medical journals.  When you try to complete with blogs - keep in mind that you are competing with a low standard.  That turns out to be no competition at all.  


George Dawson, MD, DFAPA

Reference:

1: Essock SM. What to Do When the Managed Care Firm Says No.  JAMA Psychiatry. 2016 Sep 28. doi: 10.1001/jamapsychiatry.2016.2409. [Epub ahead of print] PubMed PMID: 27680607.

Supplemental -  The 4 x 6 Card on Real Health Care Reform

No room for this in the original above.  The solutions to businesses and business managers making medical decisions about your health care is like most political quagmires in this country - very simple.  You can fit it on a 4 x 6 inch index card.

It goes like this:

1:   All managed care (MCO, MBHO) decisions are between the patient and the company.  The doctor is out of the loop.  The doctor advises the patient, the company says yes or no on the payment.  The doctor may have an alternative or the doctor may not.

2:  The doctor does no appeals , paperwork, reviews with the MCO.  Why would he/her?  The doctor does not work for the MCO and does not get paid for all of the time it takes to engage in what are business processes.  The doctor should not care what anything costs the MCO.  They have a tower of MBAs with nothing else to do but figure that out.

3:  The same process is true for PBMs (pharmacy benefit manager) - the pharmacy equivalent of MCOs.  The doctor does not work for the PBM and does not get paid for all of the extra time each day to essentially justify their decisions.  PBMs have another tower of MBAs with nothing else to do but price drugs to their advantage. 

4:  The MCO is liable for damages related to any of their financing decisions that result in harm to the patient.  No federal exceptions.

5:  Each state has an independent arbitration board comprised of physicians who are actively practicing in the discipline where the decision is being appealed.  The physicians are all actively screened for conflict of interest like the Medicare Peer Review Organizations that found there was no excessive use of mental health services or anything else in about 1998.  The arbitration board should contain only physicians - no insurance company insiders dedicated to shield the managed care industry.  Direct appeals by the public should be encouraged with the same amount of vigor that the public is actively solicited to complain against their physicians.   

Steps 1-5 above would assure physician recommendations in the best interest of you the patient rather than the financial interest of the managed care organization.  Unfortunately with Managed Care 3.0,  the rationing in many cases has been internalized.  Today physicians can be in a clinic or hospital setting that has internal case managers telling them what to do.  When managed care companies rationed some places out of business they were very successful in acquiring medical groups and facilities.  In other words; the doctors, the hospitals, the clinics and the pharmacies are all owned and run by the managed care company or a shell company.  They all get their marching orders from people in the management class pretending to be medical experts.

That should be a major problem - but in the manner of Orwell - if you use the term health care reform a thousand times - most people believe it happened.

Never Miss An Opportunity To Harass A Physician

Despite some PR releases to the contrary, pharmacy benefit managers (PBM) continue to harass physicians and waste their time.  My latest inane conversation occurred after a pharmacy left their usual message about prior authorization and an 800 number about a prescription that I had written.  Unless I call the PBM and jump through all of the necessary hoops they will not cover my patient's prescription and it will likely go unfilled.  It was a newer medication and more importantly one that I had not started in the first place.  In other words, the patient had been maintained on this medication before seeing me.  That means the specific prescription had been approved from another physician a few months earlier.  I was writing this prescription because the patient did not have access to the previous pharmacy and I was the physician of record in another treatment facility.  The conversation with the PBM went like this:

PBM:  "Is this a doctor's office or a pharmacy?"
Me:  "Doctor".
PBM:  "Who is the doctor?"
Me:  "George Dawson"
PBM:  "Who are you?"
Me:  "George Dawson"
PBM: "OK - I was just checking.  What is your fax number?  I can fax you the form in 20 minutes"
Me: (fax number given)
PBM: "OK - you will need to complete the form and then fax it back to us and we will have 15 days to make a determination?"
Me:  "Do you understand that the patient needed this medication two days ago and I just got a notification about this today?"
PBM:  "That is the patient's policy.  We can do an expedited review and give you a determination in 3 days if you like?  But that is in the patient's policy.  We have either 15 days or 3 days to make a determination.  Do you have any questions about that?"
Me:  "Well no I do not.  I am only concerned about appropriate medical care and this delay is not appropriate medical care.  I don't care about your policies.  Your policies have nothing to do with appropriate medical care."
PBM:  "Is there anything else that I can do for you today?"
Me:  "No there is not."

I expected to receive the fax in 20 minutes but did not get it until the next day.  The form is designed to waste additional physician time.  It could have been pre-populated with all of my information and the patients information - but it was not and I had to complete the form by hand.  There were two sections on the form that had to do with failed medication trials.  One wanted specific dates.  Since I am a consultant I do not have specific dates and my experience with most patients is that they have a difficult enough time with the names of medications.  I do know that the patient had tried 8 different medications from the same class and stopped them due to lack of efficacy or intolerable side effects.  I added them to the section and wrote "refer to the previous section" on the redundant form.  Total time to complete the form and try to figure out what they wanted was 20 minutes.   I was seeing other patients it took me an additional 2 1/2 hours to complete the form and fax it.  The 72 hour clock started at that point but there was no place on the form to request an "expedited review".  

I have several posts about PBMs on this blog.  They all have the same modus operandi.  PBMs are at the very minimum a significant delaying action.  They are hoping that the physician, the patient, or both just give up and either withdraw the prescription or opt for a much cheaper generic prescription.  There are a couple of significant problems with that theory.  The first is that all generics in the same so-called drug class are not equivalent.  Any physician with a modicum of experience knows that individual patients have highly individualized responses to medications that are broadly similar and that there are generally sound pharmacological reasons for those responses.  Secondly, physicians have been prescribing less expensive generics medications for decades now and if a new unique medication is being prescribed the odds are very high that the person has not responded to that medication.  In the example given here,  I had a list of 8 medications in my record that failed due to intolerable side effects or a lack of efficacy.  They were all inexpensive generics.  I listed them on the form and faxed it back to them.

This behavior does highlight an important difference in ethics between physicians and medical businesses.  In every case where I prescribe a medication for a patient, the medication is carefully selected and monitored for how well it is tolerated and the effectiveness.  The ethical concept here for physicians is to provide continuity of care for the patient.  That is the reason that I am obligated to provide follow up prescriptions to patients who leave one care setting and go to another.  The PBM obviously has no similar constraint.  I would argue that their 15 or even 3 day policy ignores the fact that the patient needs the medication right now.  The telephone conversation makes it explicit - the company cares more about the policy than the patient who needs the medication.

The political process in all of this is frequently ignored.  How is it possible for a private company to waste so much physician time and interfere with patient care?  A long time ago the healthcare industry and its friends in government sold the American public on the idea that businesses should ration health care.  They sold that idea with rhetoric about how physicians were greedy and tended to squander health care dollars on unnecessary tests, surgical procedures and medicines.  They sold that idea in spite of the fact that the largest independent review organization of physicians documented a trivial amount of excessive resource use.  Businesses are now firmly entrenched as middle men whose only job is to ration health care and that includes prescription medications.  They do that in part by having physicians make tens of thousands of calls like the one outlined here every day and essentially leaving that physician and their patient in the lurch.

Health care businesses currently have the best of all possible worlds.  They are funded by mandatory health care insurance that is essentially the second largest tax on all Americans.  The annual health care premiums easily exceed property taxes, state income taxes, and state sales taxes for almost all Americans.  The does not include the amount of physician and patient time that is wasted by these rationing tactics.  In return Americans get a system of corporate management that consistently places the interests of the corporation and corporate profits ahead of them.  They talk like they are competitive businesses - but they are in fact some of the most heavily subsidized businesses in the US and nobody seems to make the connection between the most expensive health care system in the world and this corporate welfare.

It is well past the time for change and the first step should be to return medical decision making to physicians and stop pretending that a for-profit company cares more about patients than the monied interests of the corporation.


George Dawson, MD, DFAPA

YOUR PATIENT IS UNABLE TO START YOUR PRESCRIPTION

Just when I thought that prior authorization could not get any worse, I see a fax with that headline.  I guess the business geniuses who thought it was a good idea to send me that fax never stopped to consider what was wrong with that idea.  What could that possibly be?  Let me see, I have made several comprehensive assessments of a medical and psychiatric disorder that is extremely complicated, selected a medication that was seen as appropriate by medical consultants treating another major medical problem,  did all of the medical screening for this particular medication including a meticulous search for drug interactions across 3 different data bases, thoroughly assessed the patient for side effects and complications from this particular medication and stabilized the patient on that medication.  I also had a detailed informed consent discussion with the patient for this medication and not a general class of medications.

Remind me why my patient is unable to start the medication - - - Oh that's right:

YOUR PATIENT IS UNABLE TO START YOUR PRESCRIPTION BECAUSE WE WANT YOU TO PRESCRIBE THE CHEAPEST DRUG OR THE DRUG THAT WILL GET US THE BIGGEST KICKBACK FROM THE PHARMACY AND THAT IS WHY WE ARE IGNORING THE FACT THAT YOU HAVE PRESCRIBED A GENERIC DRUG AND WE THINK THAT ALL DRUGS IN ANY GENERAL CLASS OF MEDICATIONS CAN BE SUBSTITUTED FOR ONE ANOTHER AND OF COURSE WE DON'T REALLY CARE ABOUT THE TIME AND EFFORT EXPENDED IN THE EVALUATION AND TREATMENT OF THIS PATIENT AND THE FACT THAT IT WAS SPECIFIC TO THE DRUG YOU PRESCRIBED AND WE DON'T REALLY CARE ABOUT WHAT HAPPENS TO THIS PATIENT BECAUSE WE ARE IN THE BUSINESS OF MAKING MONEY AND WE HAVE NO PERSONAL RESPONSIBILITY TO THIS PERSON AND YES YOU WORK FOR US AND YOU WORK FOR FREE IN ORDER FOR US TO BE ABLE TO DO THIS.

That simple 8 word phrase says everything about how medical care in this country has been corrupted for the enrichment of companies that make money by denying or interfering with care that has been carefully prescribed for patients by the doctors who know them the best.

A serious rewrite is needed for their fax cover sheet.

George Dawson, MD, DFAPA

Why the Practice of Pharmacy Management is Another Business Hoax

I had the pleasure of dealing with another Pharmacy Benefits Manager (PBM) recently.

It all starts with a fax from a pharmacy anywhere in the United States.  The usual pharmacy fax that looks like a telegram.  I know that because I can recall seeing railroad telegraphers in action in the 1950s and know what telegrams look like.  Pharmacy faxes have that appearance.  A partial Rx was listed on the front basically the drug and number of tablets with no instructions.  The "date of request" was actually 5 days earlier than the date I got the fax.  I pulled up the record and called the 800 number and listen to the usual disclaimers about why I might be recorded.  I don't hear the real reason.

The conversation went something like this:

PBM1:  "Can I verify the patient's identification number?"
Me:  I gave the 10 digit number
PBM1:  "Was that _ _ _ _ _ _ _ _ _ _?"
Me:  "Yes"
PBM1:  "Can I verify the patient's name and date of birth?"
Me:  I recite that information.
PBM1:  "Can I verify your name?"
Me:  I say my name.
PBM1:  "Can I verify your title?"
Me:  "Staff psychiatrist."
PBM1:  "Can I verify your secure fax number?"
Me:  I look it up and say it.
PBM1:  "Can I verify your office number?"
Me:  I state my phone number.
PBM1:  "Can I verify the medication?"
Me:  I state the name of the generic medication.
PBM1:  "Well I am going to have to transfer you to a pharmaceutical benefits manager.  I also need to tell you that person will need to do the same verifications that I just did.  Is there anything else I can help you with this morning?"
Me: (suppressing the remark that they really have not done anything for me so far except waste my time) "No I guess not."

At that point I am connected to a different line and listen to the same disclaimers about being recorded.  I am eventually connected to the second staff person who goes through the first nine steps of the verification process again and then gets into a whole new area:

PBM2:  "Can this person not take the full dose of the medication?"
Me:  "What do you mean?"
PBM2:  "The medication in this case seems like a lower dose.  Can they not tolerate the full dose?"
Me:  "Let me say that I am reading this out of the record and I assume it is the same record you have, because I am looking at an exact copy of the prescription.  I am covering for another physician and his prescription clearly states that the patient is to get two weeks of the medication and take three tablets a day."
PBM2:  "OK I have to fax this information to the pharmacist.  The turn around time is 48 to 72 hours unless I mark it as an expedited review.  Then you can get it back in 24 hours.  Do you want me to mark it as expedited?"
Me:  "I don't know what difference it will make.  Today is Friday and there is nobody in this clinic on the weekend.  The prescription is already delayed by 5 days.  I don't know what difference an expedited review is going to make."
PBM2:  "All right I will send it to the pharmacist.  Is there anything else I can help you with today?"

More wasted time.  The entire length of time it took to listen to the recordings, recite data that the PBM already had to two different people and not get an answer on the "Prior Authorization" was 20 minutes.  Not only that but this company continues to use me as their surrogate in that they are not contacting the pharmacy but sending me another fax to deal with in the next 24-72 hours.

This is a simple vignette that illustrates the malignant effects of business and Wall Street on the practice of medicine in the United States today.  I don't want to leave out the effect of every state and federal politician since Bill and Hillary Clinton suggested that giving businesses unprecedented leverage over physicians would be a good idea.  If you read the vignette you have seen how a business can waste at least 20 minutes of a physician's time,  prevent a patient from getting a timely prescription refill, and in the end leave the physician responsible for what is a business decision made to make more money for a company that has no direct responsibility to the patient.  And all of these manipulations are for a generic low cost medication.  A reader might not realize that physicians often see 10-20 people per day and in many practices have only 15-20 minutes to see each patient.  That means that they could easily spend as much time getting a single prescription approved as they did assessing the patient.  The additional business genius here (how many MBAs did it take to think this up?) is that by sending the final fax back to the physician rather than the pharmacist, it leaves the physician on the hook for being blamed for the prescription not being refilled.  How many times have you heard from a pharmacist: "Your doctor's office did not call us back yet?".  In how many cases was it due to delay that I just described?  To recap, it takes the PBM anywhere from 5-8 days to handle a decision about a medication that I turned out in 20 minutes.  But wait a minute, it takes the PBM 5 - 8 days plus 20 minutes because this decision was already made a week ago by a physician.

Hoax is not a strong enough word.

George Dawson, MD, DFAPA


Supplementary 1:  I could not fit this in to the above post but I also thought about how medical businesses are caught up in customer satisfaction surveys to show how great they are.  In that case they are banking on the fact that they can use physician qualities or psychological tricks rather than real measures of medical quality to get "performance scores" that they can use for marketing purposes.  I would suggest that anyone who is handed a customer survey by a health plan clinic or hospital remember their pharmacy experience when they complete that form.  Let them know that you are very dissatisfied that your prescription was delayed or changed just so one of their contractors could make a few bucks.

Supplementary 2:  I have several posts on this blog about PBM and managed care delaying techniques.  I came across and excellent post by a financial blogger on how her interaction with the same insurer has changed over time.  I would really like to see more people come out with their experiences and go public.  Feel free to post it here, but don't name the actual company.  Post only your experience.  I know for a fact that PBMs monitor this blog, because I got called by one of their VPs within 12 hours of naming the company.  I will only be able to do that  when I am no longer employed.

Supplementary 3:  Just a reminder that this is not my first prior authorization post and it probably won't be the last:

Prior Authorization - A Legal Document?

25 minutes is 25 minutes - The Prior Authorization Rip Off Continues

Prior Authorizations - An Incredible Waste of Time

Prior Authorization - A Legal Document?

As part of the continuous harassment that is prior authorization, I recently received a form in the mail.  It was a repeat of one that I had already signed and faxed in. The only difference was this boilerplate attached to the bottom"

"I attest that the medication requested is medically necessary for this patient. I further attest that the information provided is accurate and true, and that documentation supporting this information is available for review if requested by the claims processor, the health plan sponsor, or, if applicable, a state or federal regulatory agency. I understand that any person who knowingly makes or causes to be made a false record or statement that is material to a claim ultimately paid by the United States government of any state government may be subject to civil penalties and treble damages under both the federal and state False Claims Acts. See, e.g., 31 U.S.C. §§ 3729-3733."

I suppose I should be grateful that the PBM in this case did not attach the 14 page federal statute. And that's right, this statute is a Civil War era statute that I am sure no legislator at the time or since then would have applied to the practice of medicine. What are the implications?

1. First is the clear alliance of PBMs with the federal government. There is no clear separation of where a private for profit business ends and the government begins. I have never sent out a form or a letter with a warning that governments at any level might enforce my recommendations or services. In fact, I have complained numerous times to government officials and agencies about managed care companies at several levels only to be politely told "We can't help you." Probably because they are tripping over one another to help out the managed care cartel.

2. Secondly (and this is a recurrent theme), we have the illusion that health care companies are policing doctors and holding them accountable. That's right - the same industry that is basically one of the largest taxes on most Americans and the same industry that has dismantled mental health care and transferred the mental health care of millions of Americans to correctional facilities. There is also an implicit threat very similar to the threat I wrote about during the billing and coding era.

3. The propaganda effect - practically all managed care intrusions into the practice of medicine are designed to shift financial and clinical risk to physicians. That would includes all of the other managed care schemes like report cards, capitation, pay-for-performance, utilization review, managed formularies and all other schemes to shift risk onto doctors. The net effect of this propaganda has been to adopt the propaganda as somehow being normative. The worst effect is that these insurance companies and MBAs push the propaganda as though it is scientific fact. It not only lacks scientific merit but they frequently do not know how to analyze the data. The best example I can think of is using the PHQ-9 to "measure" depression treatment in the state of Minnesota. This is not only an invalid application of the screening tool, but the state clearly does not have any way to analyze the longitudinal data in any scientific manner.

The blizzard of propaganda from the managed care industry has been a positive for them. It has such a deleterious effect on physician morale that nobody seems to be up for a fight. They have actually launched a new wave of propaganda that is very similar to the initial wave that was used to justify managed care in the first place. We are now seeing "collaborative care" studies that claim very positive results. Medicine and psychiatry in particular seem desperate in the face of managed care propaganda. One of the front page headlines in this month's Clinical Psychiatry News was:

Future of psychiatry may depend on integrated care.


I would submit that it does but not for the reasons claimed in the article. Integrated care will result in psychiatrists with considerable less knowledge than they currently have and they will be totally marginalized without a clear set of problems to treat. The only reason psychiatrists have not been put out of business so far is that we successfully treat a set of problems that nobody else does.

Standing around in a primary care clinic looking at PHQ-9 scores and monitoring the rapid and random prescription of antidepressants by nonpsychiatrists seems like a job for an MBA rather than an MD.

I am sure at the proper time, some business type will come to that conclusion and psychiatry in managed care systems will politely disappear.........

George Dawson, MD, DFAPA

25 minutes is 25 minutes - The Prior Authorization Rip Off Continues

I can still recall when I was referred to my first web site for a prior authorization of a prescription medication.  My first thought was: "Great - I am going to have to open up an account somewhere so that I can work as an uncompensated employee of a PBM."  It wasn't quite that bad but it wasn't good either.  Online prior authorization request are often hyped as the solution to the ongoing physician harassment by PBMs.  They claim to be faster that the usual fax or telephone methods.  From the scenario I recently posted it is hard to believe that they could be any slower.

In this case I had to be the data entry person and enter data from a fax from the pharmacy and the demographic section of my EHR onto two computer screens.  After establishing that all of the correct releases were in place, that involves going between these screens and supplying data that physicians typically don't ever use and therefore do not care about.  In this case it was health insurance data - the group number and name of the policy.  Remind me why I went to medical school again.  Luckily I work with an excellent staff, but it meant getting up and finding the right person to get me this information.  I can imagine that there are a number of settings where it might not be listed.  In that case you cannot complete the form.  It just locks up there in cyberspace and does not allow you to complete and submit it.  The form is actually a request for prior authorization and you have to do it even if the patient has been taking the medication for some time.

In the previous post I pointed out that some members of my state psychiatric society had developed a form that included data on previous medications from the class in question that were either not tolerated or failed.  Of all of the people I have seen, there are very few people who can provide that level of detail over any 10-20 year span of medication trials for disorders than can affect memory and motivation.  I usually provide a checklist to prompt people as shown below.  In many cases there are surprisingly few responses until I show them the checklist.  Medication names are basically medical jargon at its best, and people outside of any field who are unfamiliar with the jargon are less likely to recall these terms.  Filling in the past medications for a prior authorization is problematic for that reason.  Filling it in is also problematic if the patient has been seen for years.  Somebody still needs to go in and search for the medications.  Most EHRs have poor search capability for classes of medications and even if there is one table somewhere it will not say whether the medication failed or was not tolerated.  Without that information the form cannot be completed.

With the wonders of the Internet and computers, prior authorization remains a waste of time.  The forms are not designed for physicians to complete and the human factors involved still require a lot of time.  No physician I know has 20 - 25 minutes to waste on form completion for every moderately priced prescription that they write.  No physician I know has that kind of time to waste irrespective of the cost of the drug.  The phenomenon has been studied to some degree (1) and the actual costs are very high.  One study showed that physicians spend at least 35 minutes a day on this activity and required 0.67 FTE non-clinical staff  per FTE physician.  The total annual cost of the physician and non-clinical staff time was $85,276.  That is nearly 4 times as much as Canadian physicians (2) and I am guessing that most of that is due to prior authorization.  That translates to an annual figure of $23 to $31 billion dollars annually (3) to medical practices in the US.  When I say that I have done a lot of free work for managed care companies and PBMs I am not kidding.

There has been some additional data available about prescription drugs used for psychiatric indications in a report from SAMHSA (4).

I think that it is apparent from the graph that the growth in medication spending is more likely to be due to patent protection of name brand medications than excessive prescribing of expensive drugs and the pricing structure of specific pharmaceutical companies.  For a graphic showing some of these patent expirations check out this link.  I can recall the clozapine prior authorization procedure in this state when it first became available in the 1990s.  Clozapine prescribing was limited to registered psychiatrists and for every prescription you had to call a PharmD in the Department of Human Services and recite the diagnosis and white blood cell parameters.  It did not take long to realize that the expense of the drug and the associated monitoring was not a determining factor in the prescription of this medication.  The argument has been made by some that clozapine was not used when it might have been useful because of the barriers to prescribing it.  Those barriers have been widely recognized by psychiatrists and the prior authorization was not a determining factor.  It was discontinued in about 2 years and most of the companies who currently handle it have an expedited enrollment in their registry that is faster than most medication prior authorizations.

If PBMs want to reject pharmacy claims they can do it easily on business grounds rather than involving physicians.  They can also just charge a high copay.  This is clearly a high cost problem to physicians, clinics and hospitals.  Eliminating it would result in more saving than the mythical electronic health record dividend.

George Dawson, MD, DFAPA

1: Sakowski JA, Kahn JG, Kronick RG, Newman JM, Luft HS. Peering into the black box: billing and insurance activities in a medical group. Health Aff (Millwood). 2009 Jul-Aug;28(4):w544-54. doi: 10.1377/hlthaff.28.4.w544. Epub 2009 May 14. PubMed PMID: 19443478.

2: Morra D, Nicholson S, Levinson W, Gans DN, Hammons T, Casalino LP. US physician practices versus Canadians: spending nearly four times as much money interacting with payers. Health Aff (Millwood). 2011 Aug;30(8):1443-50. doi: 10.1377/hlthaff.2010.0893. Epub 2011 Aug 3. PubMed PMID: 21813866.

3: Casalino LP, Nicholson S, Gans DN, Hammons T, Morra D, Karrison T, Levinson W. What does it cost physician practices to interact with health insurance plans? Health Aff (Millwood). 2009 Jul-Aug;28(4):w533-43. doi: 10.1377/hlthaff.28.4.w533. Epub 2009 May 14. PubMed PMID: 19443477.

4: Substance Abuse and Mental Health Services Administration. National Expenditures for Mental Health Services and Substance Abuse Treatment, 1986–2009. HHS Publication No. SMA-13-4740. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013.

Supplementary 1: I received a prior authorization fax today about two weeks after the original post.  It contained a number of checkboxes that were very crude approximations of the decision making process for prescribing the drug.  Since the strategy itself serves no useful purpose, I continue to conclude that this is a process designed to slow down and possible thwart the prescription process for an FDA approved drug, simply because of high cost.  Any delay involved makes it less likely that the patient will pick up the prescription and increases the likelihood that the fax will get lost in the process.  

Prior Authorizations - An Incredible Waste of Time

Anyone who has read this blog in the past is aware of my opinion of middlemen in health care and how they waste everyone's time and run up costs.  Pharmacy Benefit Managers (PBM) remain there right up at the top.  The PBM is the company that your doctor calls to get authorization so that an insurance plan will pay for all or part of a specific prescription drug.  It has never been more clear to me that their sole function is to be an obstacle to the physician, the pharmacist and the patient.  The goal of that obstruction is to increase the likelihood that anyone of those parties will give up at some point and either not fill the prescriptions or accept a different product that is less expensive, less effective, or one that has more side effects.  I am sure that the pharmaceutical companies have gamed the system to make it harder for PBMs to deny claims on a scientific basis.  They can do this by maximizing the number of FDA approved indications up front.  In many cases that results in a product with multiple diverse indications so that the newer medication can be prescribed based on secondary indications.  The physician, pharmacist and patient are left to deal with all of the unnecessary bureaucracy in between.

I posted my interaction with a PBM sometime ago and named them in that post.  I learned about the power of corporate America as a result of that post.  The VP of the company involved called me the next morning and wanted information about the patient involved.  One thing led to another but the bottom line was that I pulled that post as a result of that sequence of events.  Since my position has not significantly changed since then, the companies involved here will remain nameless.  Keep in mind that identical transactions occur tens of thousands of times per day in the United States as PBMs and pharmaceutical companies battle for the healthcare dollar at your expense.

I am still working on the theory about how the VP of a PBM hears about a post on an obscure Internet blog and calls me the next day.  The only three theories I have at this point are:

1.  NSA grade Internet surveillance system by the managed care cartel.

2.  A reader wants to see me silenced because they disagree with my viewpoint or just dislike psychiatrists.  They forwarded the link to the company named in my original post.

3.  My reputation as a tireless crusader against managed care and all of its associated systems.  Well not so much a crusader, but there have been some memorable moments.  Like a conference where I was speaking out against managed care - rather vehemently only to have the VP of one of these organizations remark:  "Dr. Dawson - don't you work for a managed care organization?"

If I did - they never censored me.

Back to the case at hand.  I was called originally by a pharmacist and had no information about the situation.  I had to call her back and ask for a fax.  I got the fax and it contained the prescription and a number for the PBM.  I called and got their endless and indecipherable telephone queue.  After typing in the correct identification number 3 times and saying it once (I thought I would forgo the voice recognition system that is set up to not work) I was put on hold and connected with a human.  He asked me to "verify" in a line by line manner all of the data already on the faxed form.  After wasting those minutes he talked about pulling up the prior authorization points as though he was going to call in another person for that detailed process.  After  a long pause (I am sure that many of my colleagues lose it at this point) he asked me the indication for the drug.  This drug has only one indication and I told him.  He said:  "It's approved."

That sequence of events, taking a total of about 20 minutes would be enough to piss off any intelligent person, but then he said:  "The office can call the pharmacy and tell them the prescription is authorized"  I was momentarily confused and said "What office?"  He said: "Your office."

That's right.  Here we have a sequence of events that starts at the pharmacy with the PBM telling the pharmacist that prior authorization is needed.  The pharmacist has to talk to me twice on the phone and send me a fax.  And I have to complete this waste of time by calling and acting like an agent of the PBM.  Just to be sure that I wasn't being totally lied to I asked the pharmacist if it was true that the physician's office had to call and complete this sequence from hell.     Her response was "It's about 80:20 from the doctors' offices."

Call me a dinosaur.  Call me a hot head.  But this exercise in helping corporate America make more money, while taking valuable time away from me, my employer, my patients, and my family is an abomination and a manipulation.  It can exist only in a country where corporate welfare is the rule of the day and conflict of interest is at all levels of government.  From the perspective of corporate America prior authorization is a good way to get physicians and pharmacists to work for them for free.  From the physician's perspective - it is a complete waste of time.


George Dawson, MD, DFAPA

Supplementary 1:  Although the sequence of events listed above may sound incredible it is not.  I have dealt with PBM telephone queues where there was no way out.  You could not enter the numbers by keypad or say them through voice recognition.  There was no way to speak to a human.  I had to call the pharmacist back and explain that the prior authorization through the PBM was basically a sham and if the patient wanted the medication they would need to pay for it out of pocket.

It would be a lot more honest if the PBM would just tell people: "We make money by denying your prescriptions and in an ideal world we would prefer to not have to pay for anything."

But I guess that would be bad for public relations.

Doubling Down on The Miserable Patient

The need for managed care and the efficiency of the electronic health record are two of the biggest myths in the American health care system today.  Here is what really happens.....

I have had the occasion to be a miserable patient for the past 6 weeks.  That is what happens when you have asthma and nothing works or at least nothing seems to work very well.  Throughout the course of the illness I have dutifully kept my primary care physician up to date, but so far I have ended up seeing 6 different physicians over that time.  I received prescriptions for three different inhalers, a nebulizer machine, and two different varieties of nebulizers - albuterol and levalbuterol.  Hundreds of dollars of medications not covered by my health insurance that don't work or cause significant side effects.  The levalbuterol was prescribed because it was supposed to have fewer side effects and it worked out just the opposite and caused significant side effects with a heart rate up to 140 beats per minute.   I needed to take these treatments 3 times a day followed by another inhaler.  This is a story of what should be a very simple task of getting enough medicine to keep breathing and in this case it is the albuterol sulfate nebulizer solution.  For anyone not familiar with this product it comes in disposable 3 ml plastic vials.  You just crack it open and pour it into a nebulizer machine and inhale the solution until it is gone in about 5-10 minutes.

The nebulizer ampules come packaged inside a foil envelope inside a box.  The prescription on the other side of this box reads: "Nebulize 1 vial every 6 hours as needed for wheezing or shortness of breath."  Assuming that I continue to use them at a rate of 3 vials, that is about 90 per month.  About a week into it, I noticed I had just a couple of vials left and called the pharmacy to get more.  This is how it went (M=me, P=pharmacy, from memory and not a transcript):

M:  Yes - I am calling to refill a prescription for albuterol nebulizer solution (details given)
P:   Sorry but you have no refills on that prescription we will have to fax your doctor (reads MD name)
M:  That was the urgent care doctor, my doctor's name is Dr. Smith (details given)
P:   Well we will have to fax him then.
M:  I think you may have made a mistake on the original prescription since the paperwork I have from urgent care says that I should have gotten 75 vials and I only got 25 (see lower left corner of the label)
P:   No that is correct, we dispense them by volume rather than number.  The insurance company mandates that we do it that way - like cough syrup.
M:  That doesn't make any sense to me.  Each one of these vials is supposed to be a single dose and if I am taking three a day that is 90 vials per month.
P:   The only other way to get more vials is if your doctor writes "90 vials" on the prescription that he sends us.....
M:  He already wrote 75 and you gave me 25.
P:   No he has to write "75 vials" and spell out "vials".

At that point, I leave both a voicemail and an e-mail through the health plans messaging system for my personal physician to send in a new prescription for 75 vials of the solution.  The next day we are having one of the largest snow storms of the year and I am commuting 80 miles a day on glare ice and no visible road surface.  My commute time is 2 to 3 times normal.  I call ahead to make sure the prescription will be ready:

M:  I am calling about that albuterol nebulizer solution.
P:   We got the prescription from your doctor, but the insurance says they won't approve it because it is too early.
M:  What do you mean it's too early?  I am using it exactly as directed and you are only giving me 1 weeks worth of medication at a time.  How can it be too early?
P:   Well that's what they are saying....
M:  Look - I need this medicine to breathe.
P:   OK the medicine is approved.

I am questioning what is happening here.  I know she was not on line with the "insurance company".  Why did she suddenly change her mind on giving me a medication that I am essentially paying for out of pocket?  Do they have a secret directive that tells them to only give up the medicine if the patient appears to be in respiratory distress?  Why does the high deductible insurance have anything to say about this anyway?  They are policing my prescriptions for non-addicting medication and they have become an obstacle to my health care.   It made me think about all of the "Dear Dr." letters that are sent out by pharmaceutical benefit managers (PBMs) and managed care organizations (MCOs) where they claim their want to "partner" with physicians to improve the overall health care of the patient.  It is typically advice about drug interactions.  They rarely have the drugs right and never have the accurate prescribing physicians correct.  Is this how "partnering" improves my health?  Was she just bluffing to keep insurance company money off the table?  Are big retail pharmacies that intimidated by managed care?

I didn't have time to figure it out.  The snow was still coming down and there was a question about whether or not I was going to make it with four wheel drive.  An hour and a half later I pulled up to the pharmacy drive through and picked up a thoroughly stapled bag containing the vials.  I tore it open in the parking lot and my suspicions were confirmed.  There was another box of 25 - 3 ml vials, not the 75 I had requested or the "75 vials" that my physician was supposed to have ordered.  Two days of work going through the most sophisticated electronic health record available and nothing had changed.

This is one isolated example of a sequence of events that probably repeats itself tens of thousands of times per day.  It doesn't take much to realize that the combination of obstacles and ineffective medications that occurs by this process is a windfall for both the managed care industry and the pharmaceutical industry.  If you decide that you want to investigate it and find out exactly what went wrong, that is a full time job.  If you want to file a complaint with the state (What - a wheezing asthmatic needs nebulizer solution?) you may not ever be able to get that accomplished.  From working both sides of the prescription process, all that I know is the system is set up to obstruct care.  These unnecessary processes waste everyone's time and money.  It doesn't matter if there is an electronic health record if it means the patient is driving 40 miles back and forth to the pharmacy per month instead of 10, making another 6 calls through time consuming automated telephone queues and paying another 3 copays.  This activity is all based on the false premise that an electronic health record, an algorithm or a business strategy is more important to your health care in the long run than your physicians input.

Nothing could be further from the truth.  

George Dawson, MD, DFAPA

Supplementary 1:  It is one week since the original post and the pharmacy/insurance company insisting on dispensing me one week of nebulizer solution instead of one month as requested.  I called in for a refill yesterday and asked if it would be for one week or one month.  The pharmacist told me exactly the same thing they did last week - they have to submit a request to my physician for the correct number of ampules.

To briefly review, that request has been made by me four times (twice to MD office by phone and secure e-mail and twice to the pharmacy).  They did tell me I could pick up another weeks worth of the medication while I wait for the larger prescription.  I went ahead and did that and have not heard anything on the other prescription 24 hours later.

WIll Integrity Save Psychiatry?

The answer is - it  depends on how it is applied.

In the last two days, I have seen the integrity argument pulled out.  Allen Frances is still using his bully pulpit on the Huffington Post, where it seems that anything critical of psychiatry is readily posted.  In this case, he used the text of a blogger and the timeline created by this blogger to illustrate how there was no disclosure of a conflict of interest by a group of researchers, one of whom was the chair of the DSM-5 Task Force.  The APA investigated this and acknowledged the non-disclosure of the conflict of interest.  Apparently the acknowledgement in the form of an apology from the research group and the investigation by the APA is not enough for these critics.  The blogger Dr. Nardo suggests that an "outside panel" be appointed to review his findings and the original materials again.  I cannot think of how an "outside panel" could be convened.  I have never really seen an objective analysis by an outside panel and wonder who might be selected.  And yes I am suggesting that any outside panel would naturally have a significant conflict of interest.  There appear to be many critics of psychiatry and only weak defenders.

He refers to a post by an anonymous web professional Neuroskeptic who summarized the state of things in his post as there being "no smoking gun."  He also concludes that the idea of a psychiatric critics benefiting from book sales with the same theme suggests "by which logic, every author in history has had a financial conflict of interest in their own ideas." As a student of conflict of interest that IS a logical conclusion, especially when I see links to two of Dr. Frances' books listed right below the Huffington Post article.  It is also an obvious fact that people routinely deny that applies to all human endeavors.  If I am heavily invested in any subject my "ideas" can be counted upon to be fairly subjective and consistent with my self interest whether that is academic or financial.  That is why I have read thousands of articles in Science, Nature, and medical journals in the past three decades and very few have panned out.  At a larger level it is why Ioannides could declare that most published research is false.  It is why you can count on seeing significant side effects from practically every medication approved by the FDA as safe and effective.  So yes, I am afraid that same standard applies to the critics as well as the people doing the heavy lifting and trying to prove something in the first place.  I would even take it a step further and suggest that the same transparency rules should be applied.  How much money can you make as a critic of psychiatry or the DSM?  My guess is plenty.

Both Dr. Frances and Dr. Nardo seem to be suggesting that all of the conflict of interest issues of academic psychiatrists and the way the APA handles them is sending psychiatry to hell in a handbasket.  This is a historically incorrect view of the dismantling of psychiatry in the United States.  Every day people in this country are getting inadequate psychiatric care.  It has nothing to do with the ethical behavior of academic psychiatrists.  It has a lot to do with the fact that the APA is not a very politically savvy organization and there are massive conflicts of interest interfering with the delivery of psychiatric care.  Here are a few scenarios:

1.  A depressed or psychotic but nonfunctional person is discharged from the emergency department because of a lack of "acute dangerousness" criteria.  The family is outraged but they are told: "Look there is nothing we can do because he/she is not imminently dangerous to themselves.  Upon further investigation the state has a "gravely disabled" criterion in the commitment statutes but it is practically never used.  They find that local hospitals and courts never use that criteria because the patients admitted are too difficult to treat and place.

2.  A person with acute alcohol and benzodiazepine withdrawal is sent home from the ER with a bottle of lorazepam and advised how to detoxify themselves.  They go home and take the entire bottle to get high.

3.  A person with alcoholism and depression is admitted for suicidal behavior.  She was intoxicated, depressed and staring at a handgun.  The next day the attending physician is contacted by a psychiatrist/utilization reviewer from the insurance company who has concluded the patient is no longer suicidal and they can be discharged.  He will no longer authorize payment for inpatient treatment. 

4.  A pharmacy benefit manager refused to refill a 2 week prescription by a patient's psychiatrist.  They have the pharmacist faxes a form to the psychiatrists office saying that they will only accept a 3 month prescription.  The psychiatrist takes time to explain first to the pharmacists and then 2 different people at the PBM (total time 30 minutes) the rationale for not giving a large supply of medication to a chronically suicidal patient.  The PBM refuses to change their position.

5.  A managed care company refuses to cover psychotherapy provided by a psychiatrist.  The psychiatrist explains that he is an expert in this type of therapy and the patient has been referred to him by the patient's primary psychiatrist.  The managed care company authorizes 3 "crisis sessions".  

6.  A person completes a PHQ-9 scale in their primary care clinic and they score an 18.  They see their primary care physician and say they would like to see a therapist.  They are told to take an antidepressant and to come back in two weeks to fill out another PHQ-9.  Total time of the visit is 5 minutes.

7.  A person is seen in their primary care clinic and in 20 minutes is told by their nonpsychiatric physician that they have bipolar disorder.  They are prescribed quetiapine, citalopram, and divalproex.  Within several days they are too sedated to function at work.

The are just a few examples of thousands of people everyday who are receiving grossly inadequate care based on a specific ethical principle of physician behavior.  That is the physician makes an assessment and prescribes care in what he or she believes is the best interest of the patient.  That is the contract.  There is no insurance company or government bureaucrat involved.  There is no restricted access to mental health care or pretending that primary care physicians are psychiatrists.  There is no remote "assessment" by a physician employed by a managed care company that prioritizes the financial well being of that insurance company or pharmacy benefit manager over the patient.  In fact,  I do not understand how that is ethical behavior at all.

That is the basis of the decline of psychiatry in this country.  It has taken a proportionately larger hit than any other specialty.  It is documented in detail on this blog and in E. Fuller Torrey's recent book.  The adventures or misadventures of academic psychiatrists are relevant only insofar as the APA seems to use the President of the APA as a position that academics cycle in and out of.  The idea that "psychiatrists in the trenches" are poorly represented by such a system is accurate with two possible exceptions that I can think of.  Psychiatrists in the trenches are also poorly represented by criticism of academic psychiatrists and their conflict of interest agreements and personal employment contracts.  It does nothing to address the central problems of the specialty, provides no tools that front line psychiatrist can use against all of the real conflicts of interest they face on a day by day basis, and is generally demoralizing.  Before any critics suggest that I am supporting a "whitewash" - put yourself in the position of a psychiatrist who has just put in a 12 hour day taking care of 20 inpatients and putting up with passive aggressive and aggressive MCO and PBM reviewers who have been wasting your time and interfering with your care.  You go home to read the paper and suddenly there is a major story of how unethical psychiatrists are - based on the appearance of conflict of interest.  You try to remember that last time you saw a CME event that was sponsored by a pharmaceutical company.  Then you check your files to make sure you have enough CME credits for relicensure.  As an added piece of information that same psychiatrist doesn't really care about Section 3 in the DSM-5 or the issue of dimensional versus categorical diagnoses.  They have not blinked an eye with the release of DSM-5 and won't in the future.

That is how the psychiatrist in the trenches experiences this academic exercise in conflict of interest.  I say if you want to pull out an ethical argument and use that to help front line psychiatrists, it needs to be focused on the obvious targets in managed care and the government bureaucracies that support them.

You know - the real forces dismantling psychiatry (very effectively I might add) over the past three decades.

George Dawson, MD, DFAPA

The Real Conflicts of Interest in Medicine and Psychiatry Today

I noticed some confusion around the GSK article that was recently posted.  I decided to start the New Year examining conflicts of interest (COI) in medicine and psychiatry because they are widespread.  These COI are much more widespread than the press or politicians have stated.  That is because there are more players than physicians involved and these other players are hardly ever mentioned. You would never realize that by reading the papers largely because COI is always described as a problem with physicians.  Nothing could be further from the truth.

My goal is to outline as many as possible and hopefully readers here will be able to fill in any that I might have missed.  Because I am just one guy working in his spare time, it will not be an encyclopedic listing but it will be more comprehensive than you will find anywhere in the press or possibly the existing medical literature.  It will also be more comprehensive than the typical political analysis that usually suggests that the only relevant conflicts of interest have to do with physicians making money or prescribing drugs in exchange for certain rewards.  As you will see, these may be some of the least important conflicts of interest.

A good starting point is this diagram I made that looks at all of the important conflicts of interest that impinge on physicians.  The diagram is not exhaustive. (click to enlarge)

Not all of the links are drawn and there are many smaller entities involved that have not been graphed. As you can see I have 13 major areas here that directly impact on physicians.  It is important to keep in mind the main goal or interest is the practice of medicine.  It flows from an ethical relationship with a physician.  That relationship is defined as the physician acting toward the patient in a way that is only in the best interest of the patient in exchange for a professional fee.  The modern relationship makes an important distinction in that the physician needs to be practicing scientific medicine.  The American Psychiatric Association (APA) has a policy statement with some useful definitions.  The APA defines the primary interest as "the highest level of evidence based practice, ethically based and scientifically valid research, and quality continuing education for the benefit of patients, the profession and society."  They define secondary or personal interests such as personal, financial, or professional that:  "may inhibit, distract, or unduly influence their (physicians) judgment or behavior in a manner that detracts from or subordinates the primary interest of patients and may be perceived by some as undermining public trust."  Six examples of situations that may require vigilance to prevent conflict of interest issues are given and 5 of 6 can be seen as derivative of physician relationships with the pharmaceutical industry.

The Institute of Medicine (IOM) definition of conflict of interest is: "a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest."  Note that the IOM makes no distinction about conflict of interest versus the appearance of conflict of interest.  It turns out that the appearance of conflict of interest is the common standard that is used to indict the medical profession.  The classic example that is typically given in the media is the influence of pharmaceutical representatives on physician prescribing behavior.  The recent GSK disclosure confirms that that pharmaceutical representatives were paid based on the number of product prescriptions that the physicians they visited actually wrote.  The idea is that promotional items of widely variable value (pens to pizza to golf outings to trips) and free samples led to increased prescriptions.  Free samples provided to clinics was probably also a major factor and became a mainstay for many patients with limited or no mental health benefits.  Typical press coverage suggests that the results of this type of conflict of interest are widespread and certain, but I would suggest that the great majority of physicians including many of those who were paid consultants by the pharmaceutical industry were not laboring under any conflict of interest.

Consider for a moment the conflicts of interest (COI) listed across the top of the diagram starting on the left with Managed Care COI.  I have reviewed those conflicts of interest in great detail in previous posts.  As an example consider the conflicts of interest in this post on how physician employees are managed by managed care companies.  In all cases, there is a direct conflict of interest between physicians interest and the interest of the company and its managers.  In every situation that I am aware of the physicians lose.  That is typically viewed as a plus by the business managers running the company because it allows them to do whatever they want to do in terms of closing clinics and programs, firing physicians, firing support staff, coming up with business based performance metrics that are divorced from clinical reality, and denying care when they want to.  When the conflict is framed as entitled doctors being managed for the first time in order to be fiscally responsible - apart from the obvious rhetoric the real impact on patients is lost.   That has included the rationing of psychiatric services, the destruction of inpatient psychiatry services, the elimination of psychotherapy services, and the wholesale shifting of care for people with the severest forms of mental illness to deficient state operated services and correctional facilities.

Managed Care COI is almost always transacted by an army of intermediaries.  There are so-called physician reviewers or utilization reviewers who look at records from a distance and second guess physicians actually treating the patient.  They can say that they don't think a patient needs a particular service such as hospitalization and the patient is invariably discharged.  These days many hospitals owned by managed care companies employ non-physician case managers who function the same as utilization reviewers and tell physicians when to discharge patients from the hospital.  This review process represents what I consider to be the largest conflict of interest affecting the decision making process in medicine and it is the least transparent.  You are not likely to hear about it until you or a family member are hospitalized and you are told that it is "time to go" based on an insurance company decision.  You can see from the diagram that this COI is enmeshed with federal and state governments, think tanks, and some of the other managed care rationing tactics - Pharmaceutical Benefit Manager COI and Insurance Company COI.  All of these bureaucracies can produce insurmountable obstacles to physicians trying to care for patients by denying diagnostic and treatment modalities and denying appropriate settings for care.

Staying on the Managed Care COI for a moment what do some of the other relationships imply?  A full description of those relationships would require several books to explain.  This all started about 30 years ago as a concerted anti-physician movement.  Several political forces had an interest in making the argument that the reason for the high cost of American medicine was that physicians were greedy and they did too many procedures.  The federal government set up a complex subjective billing and coding system to slow down physicians.  It was a mechanism that could be used to investigate and prosecute anyone who seemed to be billing too much.  They initially enforced these totally subjective rules with the FBI.  At some point in the late 1990s, they allowed managed care organizations to internalize this process and control over physicians using this mechanism was handed off to managed care.  Today it allows a managed care companies to look at the documentation of patient care, decide that the notes don't meet criteria for a certain bill, and retrospectively demand payment for reimbursed services based on the number of other people seen for that problem.  The relationship between managed care companies and governments allows them to reimburse whatever they want for a service and demand back as much as they want.  No other professionals have private industry and governments stacked against them in this manner.  It is a motivating force for psychiatrists to not accept government backed insurance at a higher rate than other physicians.

Managed Care COI also means that it is practically impossible for a physician to appeal a decision by a managed care company.  The appeal is to another doctor who is employed by that company.  Any attempt to go outside of the company to a state insurance board is usually not productive.  State insurance boards are after all generally run by political appointees who are insurance industry insiders.  There are no neutral parties who are free of conflict of interest who can decide an appeal of an insurance company decision.

Practically all of the major entities represented on this chart operate in a similar manner to the managed care and insurance company conflicts of interest.  They are business entities who have woven themselves deeply into the political system at all levels and they can generally do what they want to do in terms of running the US Health Care system.  In most cases they treat physicians with impunity and tolerate professional groups only so far as they can co-opt some of their ideas and make it seem like they have an interest in quality care.  They have also used their influence to introduce cost-effectiveness rhetoric into places where it makes no sense.  That is especially true for psychiatric services where many have simply been shut down because they were not "cost-effective" enough.    

Some of the other entities on the diagram are more subtle.  Journalistic COI has a few sources.  Certainly journalists have no interest in patient care or treatment standards.  They do have an interest in selling stories and in some cases books.  They have an interest in influencing people.  Many of the stories I have commented on this blog over the past year were clearly rhetorical.  Many were also the product of ignorance.  Psychiatry is the only field in medicine, where non-experts don't hesitate to put their opinion in the New York Times and the New York Times doesn't hesitate to print it.  One of the most read posts on this blog in the past year was about a Washington Post article that I critiqued for many of these reasons.

Professional Organization COI is also an interesting one.  Consider the APA represents roughly 40,000 psychiatrists but only about 40% are actual members.  When the American Board of Medical Specialties decided that they would introduce a new and onerous procedure to certify physicians in an ongoing manner instead of for life, the APA clearly sided with the ABMS despite widespread dissatisfaction by the membership.  The conflict of interest considerations here are considerable and heavily financial.  There is no scientific evidence that the proposed ABMS recertification process is a valid approach.  There is certainly no evidence that a less onerous approach that would be less stressful to physicians would not achieve the goal of ongoing professional education and public safety.

The next time you read a story in the press about wealthy physicians being paid off to prescribe unnecessary medications or to perform unnecessary surgeries, pull up the COI diagram and print it out.  The truth is that physicians are caught in a web of conflict of interest.  Those conflicts of interest are generally set up to ration services to patients; ration or deny reimbursement to physicians; maximize the profits of middlemen (MCOs, HMOs, PBMs, Insurance companies); make politicians, think tanks, journalists and critics look good; and distribute a large chunk of the health care dollar to people who are not involved in providing the services.  The impact is the greatest by far in the area of psychiatric services but at some level it affects all of medicine.  The impact on physicians is also significant.  All of the pressures on physicians as a result of these conflicts of interest widen dissatisfaction with the field and increase burnout.  Both of those factors can potentially impact physician availability and intellectual resources necessary for optimal performance.  So if your physician looks burned out - he or she may well be.  It is probably directly related to doing an additional 2 or 3 hours of work every day to satisfy the requirements of all of these extraneous conflicts of interest.  Of course that is all generally unreimbursed time.  How would most workers react to putting in a full day and then an additional 2 - 3 hours off the clock to satisfy the requirements of some outside company?  It is like working for free for another company.

That is the real cost of conflict of interest and one of the reasons that health care premiums are essentially another tax on all Americans.

Happy New Year!

George Dawson, MD, DFAPA

Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice; Lo B, Field MJ, editors. Conflict of Interest in Medical Research, Education, and Practice. Washington (DC): National Academies Press (US); 2009. Available from: http://www.ncbi.nlm.nih.gov/books/NBK22942/