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

GSK Eliminates Appearance of Conflict of Interest - Who Is Next?

Glaxo Smith Kline came out with a major announcement a few days ago.   It will no longer pay doctors to promote its drugs and it will no longer tie the compensation of its sales force to the number of prescriptions written by doctors who have been detailed about those drugs.  These are both standard practices in the pharmaceutical industry and this is the first announcement of its kind within the industry.  GSK will continue to to provide "unsolicited independent educational grants" to educational institutions or medical societies.  Pharmaceutical reps will be paid on the basis of technical knowledge and customer service rather than sales.  GSK has been fined heavily lately about promoting off label use of its products and is currently under investigation in China.

My immediate reaction to the piece was "good riddance".  For the past decade there has been no bigger issue in psychiatry than the appearance of conflict of interest with the pharmaceutical industry.  Psychiatry has been targeted more than any other medical specialty by prominent politicians, the news media, and even by psychiatrists themselves.  There are endless blogs and opinion pieces about how the practice of psychiatry has been defined by this appearance of conflict of interest.  There are several blogs out there that have gained prominence by endlessly reviewing all of these details. It has affected the way the APA does business.  It has affected the way local district branches do business.  In the end the politicians are grandstanding on it, because the PPACA (Obamacare) will apparently list any physician receiving money from a pharmaceutical company.  That was suggested as a motivating factor in the NY Times article.  Those public lists have existed in some states like the one I have practiced in for years.

To me the arguments have always come down to advertising and ethics.  From an advertising perspective would we expect people to be affected by product advertising?  Of course we would.  The buying habits of the American population are shaped by advertising.  Selling products is more of a science than people think.  The American public can easily change its buying habits and can purchase products that are unnecessary and will be discarded after a brief period of time.  They can also be sold on products like junk food that are unhealthy but designed to be sold in large quantities.  Advertising would not seem to be the ideal basis for marketing drugs to physicians, but with many new products  physicians are now bypassed and the drug is sold directly to the consumer.  If the epidemiology  of a particular problem like "low-T" is known, direct-to-consumer marketing probably leads to many, many more physician visits than a physician suggesting to their patient that they probably have primary or hypogonadotropic hypogonadism.  All a patient has to do is go to the web site and take a non-specific checklist quiz on the features of "low-T" and be in their doctor's office to get the levels done within a week.  Things will probably go a lot smoother without a physician intermediary in the loop and I am sure that much physician behavior will be shaped by the onslaught of men coming in to be tested for "low-T".  I know for a fact that psychiatrists are approached for this problem because of the overlap between the syndrome and depression.

Part of the advertising argument has always been that there are unconscious factors in play.  Really?  That is the basis for all advertising in general.  The main difference has been that pharmaceutical representatives have been schooled on the relationship aspects of the sale.  They have been taught that basically if a physician likes them or feels indebted to them for free food, trinkets like poor quality pens that never seem to write very well, a round of golf, or tickets to the Lakers game that they may be more likely to prescribe their product.  Most physicians were apparently naive enough to not realize that there was a huge marketing database out there that tracked their prescription writing to see if they were writing the required number of prescriptions for that product.  In the real heyday of marketing bonuses to physicians, companies would pay for travel to important meetings.

While the people focused on the advertising influence kept chipping away mostly at psychiatrists, they seemed to ignore two important developments that made detailing or selling to individual physicians much less relevant.  The first was restricted formularies.  I was on the Pharmacy and Therapeutics Committee (P&T) of one of the largest health plans in the state and an affiliated hospital for a total of 10 years.  During that time, the predominant factor in the decision about whether to put a drug on a formulary that would make it available to prescribing physicians was the cost.  There were very few instances where a drug was so unique that it was made available even if it was very expensive.  In those cases a drug might be available for an incurable illness that had a negligible benefit but it was included basically for public relations.  One of the other overriding themes of the P & T Committee was that all drugs in a particular class (like antidepressants) were equivalent and therefore the least expensive drug in the class could be substituted for anything else.  This potentially led to a lot of unnecessary chaos when medications fell out of favor due to pricing and patients needed to be shifted en masse to the least expensive drug.  It gave hospitals and health plans leverage in dealing with pharmaceutical companies, but in some cases the deals were complex.  As an example, in order to get a new blockbuster drug at a good price, the health plan would need to accept the same company's generic in a different class that had been removed because it was considered too expensive.  Over a decade ago, business entrepreneurs decided that there was money to be made rationing medications to health plan enrollees and now a lot of that is done by pharmaceutical benefit managers (PBMs).  PBMs are currently a multibillion dollar industry.

The second important development was generic drugs.  Practically all of the blockbuster psychiatric medications of the past two decades are now generic drugs.  Many generic drugs are easily affordable even as direct out of pocket purchases.  At that point they are no longer actively marketed by the pharmaceutical company that held the exclusive patents.  They are more likely to be the preferred drugs of PBMs and health plan formularies.  They are in that role because of a scientific approximation.  That approximation is that all drugs in a certain class, like antidepressants that have the same purported mechanism of action are equivalent and one can be substituted for another.  That is clearly false but it allows the health plan to to provide you with the least expensive medication or charge you a hefty copay for one that is not.  It also seems to not consider after market information that can even affect generic drugs.  The best example I can think of there is the FDA warnings on citalopram.  I would guess that despite the warnings, it remains a preferred drug by most health plans.  Health plans in general seem to be geared up to prescribe antidepressants at higher and higher rates.  I would take it a step further and venture a guess that most health plans have not taken a look at the data in their systems on whether or not they have observed problems related to the FDA warning on citalopram.

The ethical argument goes something like this.  Physicians should have the best interests of their patients in mind and an advertising based conflict-of-interest to prescribe a certain drug creates an ethical concern.  On the face of it, it seems like a straightforward argument.  But there are several problems with it.  For example, what is the direct evidence that this occurs - if any?  Is it really believable that a physician would prescribe a decidedly suboptimal medication to a patient based on schmoozing with a pharmaceutical representative?  There are often other factors in play.  It is common to treat people with chronic illnesses who have suboptimal response to the current therapy and who are looking for the "next biggest thing" to try.  A physician who has been detailed on the "next biggest thing" is likely to prescribe it if asked.  There is a similar dynamic with the issue of overprescribing in general.  If a patient persists in their request for an opioid, an antibiotic, a stimulant or any other drug are they likely to get it?  The recent declaration that the CDC initiative to decrease antibiotic prescribing has failed would suggest that they will.  Finally there is the dynamic of "see the doctor and leave with a pill."  There are any number of scenarios where medications are used in medical practice and other options are not even discussed.  The psychiatric cases are highlighted but it happens as frequently in cases of mild diabetes mellitus, back pain, chronic pain of various causes, hypercholesterolemia, mild hypertension and others.  Many people have described this as "the doctor was poised over his prescription pad" but the healthcare industry is set up to see people in brief medication focused visits and physician reimbursement is tied to it.   There are also patient related factors and a recent Tom Hanks interview is illustrative.  He was on a late night talk show discussing his recent diagnosis of diabetes mellitus and he said his physician told him that if he could get back to his high school body weight he probably would not have it.  His reply was: "Well I'm going to have Type II diabetes."

The ethical arguments, especially the ones I have seen constructed by physicians also ignore the general case of conflicts of interest at the professional level.  Practically every major university department allows its faculty to supplement their salaries by consulting in private industry.  In many cases that is a major source of additional income.  In some cases those professionals are involved in setting standards and their approach is much different than the wall that is currently being constructed between the medical profession and the pharmaceutical industry.  As an example, academic and industry professionals within the engineering profession are often on committees responsible for setting standards that govern all of the products within that industry.  Their approach is to include as many industry professionals as necessary rather than suggesting the academics can set the standards themselves.  Considering that pharmaceutical companies employ some of the top scientists in the world it would seem that medicine has a lot to lose if it goes along with the prevailing assumption.  The prevailing assumption is that physicians are powerless to stop prescribing expensive medications that are of questionable benefit for their patients based solely on advertising and no scientific merit.

I applaud the GSK decision even though the above cited factors would suggest that for most physicians it has only historical relevance.  I would encourage all of Big Pharma to adopt the same policies toward physicians.  But this doesn't really go far enough and it is basically a token gesture at this point.  To really make a difference I would suggest that they stop giving money to politicians.  GSK spent $1.9 million on candidates and $4.9 million in lobbying last year.  All of that money was directed at a few politicians.  It is a part of a massive industry wide contribution to politicians.  What do you think buys more influence, giving free pizza and pens to doctors or giving thousands to tens of thousands of dollars to politicians?

George Dawson, MD, DFAPA


Katie Thomas.  Glaxo Says It Will Stop Paying Doctors To Promote Drugs.  New York Times December 16, 2013.

Using A Civil War Law to Intimidate Physicians

I thought I would post this latest iteration of how managed care organizations (MCOs) and their proxies in the pharmacy benefit manager (PBM) industry are intimidating physicians into not prescribing a specific medication for you.  At some point these companies started to attach a reference to the False Claims Act, along with the usual forms they expect doctors to fill out so that you can get your prescription filled.  Intimidating physicians has always been a tactic to try to slow doctors down or stop them in their tracks.  Delaying and stopping doctors from writing prescriptions is money in the pocket of any PBM or MCO.  Intimidating physicians is also useful because it has a demonstrated effect on their behavior.  It causes them to undercode or bill for less service than they actually provided and it dates back to the 1990s when the FBI was used change the billing behavior of an entire generation of teaching physicians under the threat of large scale paybacks for "fraud" or RICO actions and the threat of imprisonment.  I have never seen an estimate of the total amount of money "saved" (as in removed from physicians) and time wasted based on these political ideas, but it would not surprise me if it was hundreds of billions of dollars.  I know it forced me not to teach residents for over a decade.  I could see no point in needing to generate a daily note that was identical to my residents' notes and they logically found it offensive.

So we have the issue of "prior authorization".  You used to get a prescription from your doctor, take it to the pharmacy, and get it filled.  In the 1990s HMOs and MCOs decided they knew more than doctors and they would adopt some sweeping measures to "reform" prescribing practices.  In some of the areas it made sense at the level of clinic or hospital based Pharmacy and Therapeutics (P&T) Committees.  Certain drugs are so specialized (eg. chemotherapy agents) that only certain physicians should prescribe them.  There has been a two decades long problem with antibiotic over prescribing and there are typically ongoing initiatives to deal with that problem.  I have not been on a P&T Committee for over three years, but I can't imagine there is nothing currently being done to curb opioid painkiller overprescribing.  There are definite reasons for intervening with prescribers on a scientific basis.  But at some point prior authorization became much more than that and some of the assumptions (like all SSRIs are alike) are not valid.  To make matters worse, the pharmacy arm of managed care companies (the PBMs) were now asking for prior authorizations on generic drugs.  Or they were asking for repeat authorizations if the prescriber changed or the patient was hospitalized and the prescription stayed the same.  These same PBMS found that the same rules did not apply to themselves.  They could frequently make deals with hospital that would involve the bundling of one medication with the same medication form the same company and they could make money off that.  PBMs had become a multibillion dollar business.

The hassle of filling out forms and making many phone calls in order to assure that a prescription is completed is more than an annoyance.  It removes billions of dollars of resources from the provision of medical care.  One study estimated that the cost for American physicians to deal with insurance  companies was $82,975 per physician or about four times higher than their Canadian counterparts.  That amounts to $27.6 billion nationwide.  That is a lot of medical care and the time jumping through hoops is never reimbursed by MCOs or PBMs.  An estimate of the losses to the treatment side for billing practices alone is about $7 billion.

The political aspects of this intrusion of business into medical practice is instructive.  Physicians are notoriously inept when it comes to politics and there is no clearer example than drug prior authorization.  What other business in the United States has to provide that level of free work in addition to the primary work in order to be reimbursed.  Do other professionals like lawyers need to waste this amount of time?  I sat through a meeting at one point where the debate was whether we could influence the length of a drug prior authorization form and get it down to two pages instead of five.  The consensus at the time was that there were probably federal rules that would not allow the form to be "streamlined" to two pages!

So now we have the streamlined form with a 14 page federal statute affixed to it.  Reading through the statute and figuring out what it means takes an attorney.  But every doctor who sees this knows what it means.  Don't rock the boat.  Don't question this government backed, big business policy that is guaranteed to waste your time and put more money into the pocket of the insurance industry.  And by the way, there is no guarantee that your patient will get the medication that you think they need, even if you jump through all of these hoops.

That is the state of health care in America today and it may be why you are standing in a pharmacy waiting to get your prescription filled.  It also may be why your doctor looks exhausted.

George Dawson, MD, DFAPA


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.

Who Runs My Drug Plan?

The real issue in pharmaceuticals used to treat mental illness is the business practices that looms as an obstacle between the psychiatrist prescribing the medication and the patient who wants to receive the medication.  I have posted about the managed care practices - specifically pharmacy benefit managers (PBMs) that get in between physicians and patients. That previous post shows a diagram from an internal memo that reveals some perspective on the PBM attitude.  The goal for them is to come up with a business argument that will either improve profits for the managed care company or justify the billions of dollars in costs that PBMs add to the health care system every year.

The National Community Pharmacists Association fights back against PBMs from this web site.  A lot of what you find is relevant for pharmacists also applies to physicians - especially wasting physician time, indirectly affecting reimbursement, and disrupting the patient-physician relationship by dictating medications that need to be prescribed that are financially advantageous to the PBM.

Some of the details provided on this site are very interesting.  One example is a $10 price spread on up to 4 billion prescriptions per year.  I once read that PBMs made up an $80 billion per year industry and it is easy to see how they can get there.  In fact, the volume strategies that they use are very similar to the financial services industry.  In both cases, political advantage has added businesses that levy another tax on consumers and do not provide any added efficiency.  It is easy to see how managed care strategies fail to contain health care inflation when the intermediaries with government advantages are set up to maximize profits and waste the time of physicians and pharmacists.  

If you are a physician, watch the "Fed Up With Phil" video and ask yourself if it isn't time to get rid of health care middlemen that are increasing costs and in many cases detracting from the quality of health care?  If you are a physician, isn't it time that you or your professional organization starting putting up web sites like this one to educate the public about managed care and all of its problems?  Isn't it time that we stopped wasting our time and money with politicians?

George Dawson, MD, DFAPA

Happy Labor Day - To All the Docs On The Assembly Line

When I first started working in medicine I was the Medical Director of an outpatient mental health clinic.  We had a staff of 8 psychotherapists, 2 nurses, and 2 case managers.  There were three transcriptionists to type up all of our notes.  Every person I saw had a typed note to document the encounter and all of the charts were paper.  There was no electronic health record.  If a person needed a prescription, I would write one or call the pharmacy and that was the end of it.  The majority of my time was spent speaking directly with patients and I could generally do all of the dictations in about 2 hours per day.

After three years I moved to a hospital setting.  There were three inpatient units with 6 psychiatrists and two transcriptionists.  One of the transcriptionists specialized in paperwork specific to probate court proceedings.  There was an additional pool of transcriptionists available 24/7 on any phone in the hospital for immediate documentation of any clinical encounter.  The admission notes were typed on two or three sheets and inserted in the chart.  Daily progress notes were typed on adhesive paper and pasted into the chart.  After I signed the note, a billing and coding expert came through and submitted a billing fee for the work that had been done.  The same process was in place with pharmacies.  Call them or send them a written prescription and it was taken care of.   Every Sunday I would go to the basement of the hospital in the medical records department and sign all of the areas I had missed to complete the charts.  It was the early 1990s and the administrative burden was certainly there but it was a manageable ritual.

Over the next decade things got much, much worse.  Even in the blur of a retroscope it is hard to say what happened first.  I would guess it was the political theory that health care fraud was the main driver of health care costs and the misguided effort by the federal government to crack down on doctors.  That led to the elimination of the billing and coding experts.  Doctors now had to waste their time in seminars devoted to making them experts in what is an entirely subjective process.  No two coders agree on the correct bill to submit.  How can you teach that lack of objectivity to doctors?  The end result is that the billing and coding people were eliminated or reassigned and doctors took on another job unrelated to medicine.

The next phase was the electronic health record (EHR).  It required that doctors learn the interface (more seminars and training).  Once that was accomplished it was decided that they could also learn to enter their own notes - either really clunky ones using EHR derived phrases or more natural ones with a fairly frequent embarrassing typo using voice recognition programs.  That eliminated the transcriptionists and required much more training. During the transition period I still went in to medical records every Sunday.  I expected to see a staff person there who I had seen every Sunday for 15 years but one Sunday she was gone - a casualty of the EHR.  The end result was doctors with a couple of new jobs and the elimination of both transcriptionists and medical records people.

At about the same time, managed care companies started to ratchet up the pain.  In an inpatient setting you could get one or two "denials" per day.  A denial is the managed care company saying that they refuse to cover the cost of care because the admission was not "medically necessary".  That is managed care rhetoric for "we have decided not to pay you."  These denials are purely arbitrary and have nothing to do with whether a person needs care or not.  The best examples at the time were people with alcoholism or addiction who were suicidal and needed to be detoxed and reassessed.  The standard managed care denial at the time was "This patient should be treated in a detox facility."  The obvious problem was that not every county has a detox facility and those that do will not accept people making suicidal statements.   So the next new job became battling with these companies who were essentially getting free care for their health plan subscribers if you did not jump through all of the hoops necessary to appeal.

Slightly later, managed care decided they could apply the same denial strategy to pharmaceuticals on the basis that cheaper drugs are as good and all drugs in the same class are equivalent.  It turns out that nether of those assumptions is accurate, but in America today business and politics always trumps medical decision making.  This prior authorization process created a blizzard of paperwork that ties up a lot of clinic time.  One study estimated 20 hours per week (across all employees) per physician  on average.  That means if your clinic has 5 doctors in it - 100 hours per week of the total hours worked is used strictly to deal with insurance companies.  It also adds another job to what the doctor already does.

So in the time I have been practicing medicine let's add the number of jobs that have been accreted into the administrative side of medicine for all physicians.  Billing and coding expert + transcriptionist + EHR interface user + voice recognition user + utilization review responder + prior authorization responder totals 6 new jobs in the past two decades, none of which came up in medical school.

With all of that "efficiency" we should expect health care costs to plummet or at least stay the same.  As we all know that has not happened.  The politics and business interests driving this are in the business of making money.  Physician and hospital reimbursement is essentially flat.  One of the easiest ways to make a buck is to have the physicians doing way more administrative tasks and fire the employees that used to do them.  You can also make money by putting up the usual obstacles to doctors doing their jobs of treating patients in hospitals or clinics until they just give up.  I have been so burned out at times that I put a cursory note in the chart to say exactly what I did.  That note did not meet coding requirements so I did not submit a bill.  At some point you just have to stop working.  I know that I am not alone in getting to that point.

So congratulations to all of the docs who are now laboring on this vast assembly line that we now call American medicine.  It is the ultimate product of what Congress, the White House and big business can do.  We can only expect continued "improvements" or "efficiencies" under the new health care law.  It is an assembly line that discourages quality or innovation and that also makes it unique.

Happy Labor Day!

George Dawson, MD, DFAPA

Politics and Prescribing: The Case of Atomoxetine

Prior authorizations for medications have been a huge waste of physician time and they are a now classic strategy used by PBMs and managed care companies to force physicians to prescribe the cheapest possible medication. The politics for the past 20 years is that all of the medications in a particular class (like all selective serotonin reuptake inhibitors) are equivalent and therefore the cheapest member of that class could be substituted for any other drug. The managed care rhetoric ignores the fact that the members of that class do not necessarily have the same FDA approved indications. It also ignores basic science that clearly shows some members of the class may have unique receptor characteristics that are not shared by all the members in that class. Most of all it ignores the relationship between the physician and the patient especially when both have special knowledge about the patient's drug response and are basing their decision-making on that and not the way to optimize profits for the managed care industry.

The latest best example is atomoxetine ( brand name Strattera.).  Atomoxetine is indicated by the FDA for the treatment of attention deficit hyperactivity disorder. It is unique in that it is not a stimulant and that it is not potentially addicting. Many people with attention deficit hyperactivity disorder prefer not to take stimulants because they feel like they are medicated and it dulls their personality. In that case, they may benefit from taking atomoxetine. The problem at this time is there are no generic forms of atomoxetine in spite of the fact that there are many good reasons for taking it rather than a stimulant. As a result physicians are getting faxes from pharmacies requesting a "substitute" medication for the atomoxetine. Stimulants are clearly not a substitute. Some people respond to bupropion or venlafaxine but they are not FDA indicated medications for attention deficit hyperactivity disorder. Guanfacine in the extended release form is indicated for ADHD in children, but it is also not a generic and is probably at least as expensive.  There is no equivalent medication that can be substituted especially after the patient has been out of the office for a week or two and a discussion of a different strategy is not possible.

I am sure that in many cases the substitutions are made and what was previously a unique decision becomes a decision that is financially favoring the managed care industry. I would like to encourage anyone in that situation to complain about this to the insurance commissioner of your state.  It is one of the best current examples I can think of to demonstrate the inappropriate intrusion of managed care into the practice of medicine and psychiatry.

George Dawson, MD, DFAPA

Psychiatrists work for patients - not for pharmaceutical companies

That should be obvious by anybody reading this post but it clearly is not. I have already established that there is a disproportionate amount of criticism of psychiatry in the popular media compared with any other medical specialty. The most common assumption of most of those critics is that psychiatrists are easily influenced by pharmaceutical companies or thought leaders who are working for pharmaceutical companies. There are many reasons why that assumption is incorrect but today I want to deal with a more implicit assumption that is that there is a drug that is indicated and effective for every medical condition.

In the field of psychiatry this marketing strategy for pharmaceuticals became prominent with the biological psychiatry movement in the 1980s. Biological psychiatrists studied neuropsychopharmacology and it followed that they wanted to apply their pharmaceuticals to treat human conditions. At the popular level initiatives like National Depression Screening Day were heavily underwritten by pharmaceutical companies and the implicit connection was that you could be screened and be treated with a medication that would take care of your depression.

From the perspective of a pharmaceutical company this is marketing genius. You are essentially packaging a disease cure in a pill and suggesting that anyone with a diagnosis who takes it will be cured. The other aspects of marketing genius include the idea that you can be "screened" or minimally assessed and take the cure. We now have the diagnosis, treatment, and cure neatly packaged in a patent protected pill that the patient must take.  The role of the physician is completely minimized because the pharmaceutical company is essentially saying we have all the expertise that you need. The physician's role is further compromised by the pharmaceutical benefit manager saying that they know more about which pill to prescribe for particular condition than the physician does. That is an incredible amount of leverage in the health care system and like most political dimensions in healthcare it is completely inaccurate.

The pharmaceutical company perspective is also entirely alien to the way that psychiatrists are trained about how to evaluate and treat depression.  Physicians in general are taught a lot about human interaction as early as the first year in medical school and that training intensifies during psychiatric residency. The competencies required to assess and treat depression are well described in the APA guidelines that are available online.  A review of the table of contents of this document illustrates the general competencies required to treat depression. Reading through the text of the psychopharmacology section is a good indication of the complexity of treating depression with medications especially attending to side effects and complications of treatment and decisions on when to start, stop, and modify treatment. Those sections also show that psychopharmacology is not the simple act that is portrayed in the media. It actually takes a lot of technical skill and experience.  There really is no simple screening procedure leading to a medication that is uniformly curative and safe for a specific person.

The marketing aspects of these medications often create the illusion that self-diagnosis or diagnosis by nonexperts is sufficient and possible. Some people end up going to the website of a pharmaceutical company and taking a very crude screening evaluation and concluding that they have bipolar disorder. In the past year, I was contacted by an employer who was concerned about the fact that her employee had seen a nonpsychiatrist and within 20 minutes was diagnosed with bipolar disorder and treated with a mood stabilizer, an antidepressant, and an antipsychotic medication. Her concern was that the employee in question could no longer function at work and there was no follow-up scheduled with the non-psychiatrist who had prescribed medication.  Managed care approaches screening patients in primary care settings increase the likelihood that these situations will occur.

The current anti-psychiatry industry prefers to have the public believe that psychiatrists and their professional organization are in active collusion with the pharmaceutical industry to prescribe the most expensive medications.  In the case of the approximately 30 antidepressants out there, most are generic and can be easily purchased out-of-pocket.  Only the myth that medications treat depression rather than psychiatrists keeps that line of rhetoric going.

George Dawson, MD

American Psychiatric Association.  Practice Guideline for the Treatment ofPatients With Major Depressive Disorder, Third Edition. 2010

Managed Care 101 – The Prior Authorization Hoax

As managed care organizations worked on how they could prioritize pricing over medical decisions they came up with various plans to “manage” how physicians prescribed medications.  I was a member of two Pharmacy and Therapeutics Committees (P & T) that  both had this as a goal.  One of those committees had a much stricter mandate in terms of saving money.  The basic strategy used by that committee was to place a drug “on formulary” or “off formulary”.  If it was “off formulary” it was not available to any doctors within the HMO to prescribe.

The idea that all drugs within a class that had the same purported mechanism of action ruled the day.  As an example, all of the selective serotonin reuptake inhibitors (fluoxetine, paroxetine, sertraline, citalopram, escitalopram, fluvoxamine) would be considered equivalent medications and the committee would decide to place the least expensive ones on the formulary.  At the time, the major controversy was fluoxetine because there was no generic brand available and the company that produced it was notorious for not negotiating prices with hospitals and health care systems.  There was an eventual appeal by psychiatrists who presented to the committee on the unique qualities of fluoxetine.  At the time it was the only medication studied in adolescent depression for example.  Eventually a rule was passed that it was nonformulary for any physician who was not a psychiatrist.

The total cost of the drug was more of a consideration than the absolute price.  Very expensive drugs were approved that had questionable endpoints based on the fact that utilization would be low and that advocates for a particular untreatable illness would want it.  So the decision of the committee and their mandate was to reduce the use of relatively more expensive drugs that would be used fairly frequently.  In some cases, the off formulary drugs were available by “prior authorization” meaning that the prescribing physician needed to usually write up an appeal and fax it to the pharmacy or health plan and in some cases make additional calls.

The health care business has a long history of introducing layers and layers of management driven largely by the amount of money involved.  If you can successfully insert more management for even a small percentage of the available health care dollars you will potentially have a multi billion dollar business.   The management of pharmaceuticals is no exception and the Pharmacy Benefit Manager or PBM was born.  The task of the PBM like the task of a P & T Committee is to control the prescribing physician and force them to choose a medication based on the lowest cost.  Individual variation between patients and all of the other variables that physicians have to take into account do not matter.  If the physician or the patient thinks that they do – it will take a prior authorization for the alternate medication.  

The PBM model was designed from the outset to take a central role in the management of prescription drugs by replacing the relationship that the patient has with their health plan, their pharmacist, and even their physician.  How do I know this?  Take a look at their game plan from an internal memo in the diagram below.  This diagram was taken from an internal memo from over 15 years ago.  The structure depicted in the diagram is the system of care that exists today and the one that 95% of patient have their benefits managed through 

The prior authorization fallacy is essentially the same as the utilization review fallacy.  The most charitable interpretation is that it assumes that a person who is not necessarily a physician and who has no personal responsibility for your care can substitute their judgment based on a cost consideration.    

The diagram is also instructive in the way that the prescribing decision (and the dispensing decision) is trivialized as a "habit" rather than a decision that takes into account the evaluation and personal knowledge of the individual patient.

Today all physicians are routinely subjected to prior authorization procedures that waste significant amounts of their time and the time of their staff in order to make seem like the PBM decision has some degree of medical legitimacy.  The cost to medical practices is huge and completely unnecessary.  If PBMs are really businesses there is really no legitimate reason that they need to include physicians in their decisions of what medication should be covered.  They just need to plainly state that to their patients and deal with the public relations problems instead of wasting about one million hours of physician time per week.  In the weeks that follow I will demonstrate just how far this business plan has infiltrated medicine and psychiatry and what the response has been to date.

George Dawson, MD