P for prior authorization

The letter P and my theme is happy things. But what comes to mind are these P words: prior authorization,  pharmaceutical, payer.

Prior authorizations are NOT a happy thing. The latest twist from insurance companies, three different ones in the last week, is that they are requiring prior authorization for old inexpensive medicines. I ordered a muscle relaxant for night time only on Thursday last week for a person with a flare of back pain. Friday I was dismayed to see that the insurance company was requiring a prior authorization. I have to prioritize the order of urgency of all the work: I did not have time. I called the patient who had paid cash for it. The insurance company wins. They didn’t have to pay for a covered medicine because they made it difficult to get. They keep the patient’s money.

Prior authorizations are on the rise very rapidly. With over 800 insurance companies, each with a different website, each with multiple insurance “products”, no one can keep up with it. It is a shell game, the ball under the cup, three cups moving, but the ball is the money and it’s already palmed by the insurance companies. I predict that this will continue to get worse. We do need a single payer system for the simple reason that physicians will not be able to hire enough staff to learn and navigate 800 different websites. I do most prior authorizations on the phone in the room with the patient: the other day we spent 35 minutes on the phone only to have the insurance company say that we had called the wrong number. Call another one. Not the one on the insurance card. We could complain to the state insurance commissioner, but my patient is afraid of losing their insurance. Time’s up. The prior authorization is not obtained, and we are five minutes into the next patient’s visit. People are finding that the medicine they have taken for 20 years suddenly requires prior authorization.

And remember: prior authorization is your insurance company making rules and extra paperwork for your physician. It is advertised as a way to save money, but it costs YOU money. Back in 2009, the estimate was that physicians in the US had to spend 90,000$ per year EACH on employees to do prior authorizations by computer or phone. And YOUR insurance dollars go to the employees at the insurance company refusing medicines and dreaming up new medicines to refuse. They change the contract. Every year and during the year. The law is now that 80 cents of each dollar must go to healthcare, not profit, but those computer and phone employees are counted as healthcare. Do we really think that is healthcare?

Take CT scans. Medicare does NOT require prior authorization. But most insurance companies do. Think about that. Is age the difference? CT scans increase cancer risk over time so physicians don’t order them by reflex.

And for pharmaceuticals, insurance companies often have an on line formulary. But it is different for every insurance “product” in individual companies. A patient and I were trying to sort out a less expensive medicine on a website and we were having difficulty figuring out which insurance she had. Multiple abbreviations and color coding and we could spend the entire clinic visit just figuring it out. Is that what medicine is in the United States? You can say that someone else in the office could do it, but the more employees your physician hires, the less time the physician will spend with you, because he or she has to pay all of those people.

If there was one set of rules, one website, I would learn it. Medicare for all, single payer, when will the United States people wake up and tell congress: if you want our vote, make it so.

P

But wait, where are the happy things? I am so happy that I still am in business in my small clinic, p for patients and patience and prayer and single payer, we will have medicare for all in my lifetime. Whether I am still a practicing physician in the US at that time is uncertain. If I can’t afford my own health insurance, my clinic will close. Wouldn’t that be ironic?

 

hypertension: The 2017 Clinical Guidelines

A visual guide to the new hypertension guidelines: https://www.medpagetoday.com/cardiology/hypertension/69399
In writing: http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults
I don’t watch television news, so I always hear about these things from patients first. “What do you think of the new hypertension guidelines?”

“Haven’t heard about them yet, so I don’t know.” Seems pretty embarrassing really, doesn’t it? Shouldn’t I be alerted as a doctor before it hits the news?

First of all, these guidelines are NOT JNC 9.

What is JNC 9, you ask?

One of the messy complications of medicine for people in the US and in the world, is that there is not ONE set of guidelines. There are multiple sets of guidelines. Take mammograms, for example. The US Preventative Task Force* said that the evidence in their review could not differentiate between yearly and every other year mammograms. They said you could do it every other year. The American Cancer Society and the Susan Koman Foundation yapped and had different guidelines, do it yearly. So as a physician I have to not only pay attention to the guidelines but know who is putting them out. The radiologists wanted yearly mammograms too, surprise, surprise.

And do you think some of it is driven by money? Well, it’s the US.

JNC 8 is the Eighth Joint National Committee and put out guidelines in 2014. Their job is to review all of the big hypertension studies since JNC 7 and put out new guidelines. JNC 8 took over a year, was multidisciplinary, and the final document was 400+ pages.

They said that if a patient was over 60, their blood pressure should be taken standing up, and the goal was under 150/90. Under 60, sitting, goal under 140/90. Normal is 120/70 and below.

Then there are pages and pages of recommendations about which medicines to use and in special circumstances, that is: diabetes, kidney failure, heart disease, atrial fibrillation, etc, etc.

The cardiologists promptly started yelling about how JNC 8 is wrong and they put out a huge study saying that people have less heart attacks if their blood pressure is 125/80 or below.

But… the heart is not the only organ in the body. My patients are 77% over age 50 and 48% over 65. Once a person hits 80, their blood pressure may drop when they stand up. Most do. And low blood pressure, well, it’s bad for the over 80 crowd to get poor blood flow to the brain or to the kidneys or to faint and break things. That is why JNC 8 is multidisciplinary: because we need geriatrics and psychiatry and ortho and family medicine to be part of the guidelines.

So these NEW and IMPROVED guidelines. Well, who is putting them out? American Heart Association, American College of Cardiology, and a bunch of other mostly heart related organizations. And they are comparing it to JNC 7, not JNC 8. JNC 8 is being ignored. This document is a mere 192 pages, with the “short” version being 112 pages.

It says that blood pressure 130/80 to 140/90 is stage I hypertension, not prehypertension, and that we should treat it with lifestyle changes. Drugs are still to be recommended at anything over 140/90, though honestly, I start with lifestyle there too. Over 180/120 is now “hypertensive crisis”, consult your doctor immediately. 140-180/90-120 is stage II hypertension.

How will this change my practice? I am still thinking about the new guidelines and who has skin in the game. The AAFP (American Academy of Family Practice) put out a link to the guidelines and then a cautious comment to the effect of “We are studying how we should respond to this.”

Before this came out, I would tell people the JNC 8 goals. I do stand the people over 60 up, most of the time. I also tell people that the cardiologists want their blood pressure lower. And then that the cardiologists mostly ignore hypertension and cholesterol guidelines anyhow. If I follow the guidelines and then the patient sees a cardiologist, the cardiologist usually changes something. Guidelines be damned.

It comes down partly to a patient’s goal. I have people come in and say, “I don’t want to die of dementia!!” I see that as an opening. “What DO you want to die from?” People have different ideals. Some say, “I don’t want to die!” but then many do think about it. Sometimes this changes their ideas about what they want treated and what they don’t want treated.

Not everyone’s blood pressure drops in their 80s. Some people develop hypertension in their 90s. I tell them. They say, “I’m not taking a drug!”

I reply, “Let’s talk about strokes.”

They usually are not afraid of sudden death, but they don’t want the disability of a stroke. Many choose medicine after all.

One of the issues with guidelines is complexity. I could spend 20 minutes with a patient just talking about hypertension guidelines and choices of drugs and side effects and why they should be on an ace inhibitor or ARB if they have diabetes…. and there are guidelines for EVERYTHING. Sometimes conferences feel like all the specialists yelling: only half of diabetics are controlled, only one third of hypertensives are controlled, family doctors aren’t screening for urinary incontinence enough, osteoporosis, lung cancer, stop smoking! And then what my patient really needs is to talk about their adult child, in jail for addiction, and how frightened they are about overdose and the grandchild and the future…..

JNC-8 flowchart: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf
JNC-8: https://jamanetwork.com/journals/jama/fullarticle/1791497
*lots of guidelines: https://www.uspreventiveservicestaskforce.org/

Little Blue Pill

Little blue pill
Little blue pill
Help me help me
I’m over the hill

Don’t wanna have sex
Nope nope nope
Little blue pill
Gives my husband hope

Can’t make a pill
Til we define the disease
Doctors would you
Hurry up please

Little blue pill
Little blue pill
Help me help me
I’m over the hill

Thought them hormones
Would make me hot
Doc was right
They did not

Hot flashes make me
Sweat and moan
No help from that
Testosterone

Little blue pill
Little blue pill
Help me help me
I’m over the hill

Doctor this
Is really no joke
My husband says
He’ll slit his throat

Can’t make a pill
Til we define a disease
They’re trying hard
Those drug companies

I think we’ll know
If they define a disease
Drug companies will plaster it
On tv

Doctor I found
Just the thing
A brand new stimulating
Clitoral ring

Don’t wanna have sex
Nope nope nope
Little blue pill
Gives my husband hope

previously published on everything2.com

the mushroom is from the olympic peninsula. we didn’t know what it was and did not eat it.