Posts Tagged ‘Blogfinger medical commentary’

Internet cartoon.


Medical practices spend an average of two business days a week per physician to comply with health plans’ inefficient and overused prior-authorization (PA) protocols. One-third of practices employ staffers who spend every second of their working hours on PA requests and follow-ups. But some relief appears to be coming, as the AMA and joins forces with some payers to fix this broken process. Read more at AMA Wire®.

This quote is from the AMA Morning Rounds:  “Physicians have, for many years, expected to face prior-authorization hurdles for a few new or unusually expensive medications or tests. But, more recently, insurers have rapidly added PA requirements to more and more treatments,”

Blogfinger Medical Commentary:  Paul Goldfinger, MD, FACC

Some of you may have experienced rejection of a particular prescription drug by your drug plan. But such rejections typically get reversed by enlisting your doctor’s help, and that would require his time and that of his staff to deal with the insurance company.  The process is called “prior-authorization.”

In the article above, from the AMA, they discuss the problem from the perspective of the physician, but I have experienced it myself, from the perspective of the patient.

And, without a doubt, the episodes of prior authorization have increased noticeably for patients, but, as discussed above, also for the prescribing physician and his staff.

And now we see insurance companies questioning even cheap generics or chronically used stable medications,  and the issue isn’t always the drug choice itself.

For example, I recently ran into this situation related to my use of a high blood pressure medication that is perhaps the number one or number two choice prescribed by doctors for their patients with hypertension.

In my case, I was doing very nicely with two 5 mg. tablets each morning of that drug   (10 mg per day)—lisinopril, an ACE inhibitor. However recently my doctor wanted me to increase the dose from two tabs each day to two tabs twice per day  (20 mg per day), ie 4 tabs per day instead of 2.

So I would need 360 tabs per 90 days instead of 180 tabs per 90 days—-a perfectly reasonable dose change.    I was notified that they would not send me my medication because it required the prior authorization process.     Meanwhile I was running out of medications while the plan would try to get my doctor to respond.  And the drug plan was contacting me by mail and phone messages to raise the PA alarm.

I couldn’t understand why this innocuous dose change was a problem—it’s a cheap drug with a zero  copay.  I was baffled, so I called the company, but the customer service representative couldn’t figure out why prior authorization was being applied to my prescription.  She advised me to wait for the process to play out.  This was unacceptable.

I  thought about the problem, and it dawned on me that maybe the number of pills was the issue, and not the medication itself.

Maybe the problem was the 360 tablet requirement, every 90 days.   Being a physician I was able to call and  speak to a pharmacist at the mail order plan. He verified that the number of pills was the problem, not the dose.

So I asked if we could change the tablet size from 5 mg. to 10 mg, making the daily dose two tabs each day.  He said “fine” and a few days later I received 180 of the 10 mg tabs.

But the warning letters and phone messages continued.  Finally I called the “prior authorization” department and told her that I fixed the problem myself. And she said, “Oh, when you get the letters and phone calls just ignore them until the matter is fully resolved.”

The best resolution available for most patients is to make sure that your doctor’s office staff has done their job with the paper work. It might  be easier to resolve if you buy your meds from a local pharmacy.  If you have a mail order pharmacy, as I do, and you are running out of pills, one of the local pharmacies will help you get a temporary supply, assuming that the left hand and the right hand at your drug company can resolve the problem.




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April 4, 2012.     “The American College of Cardiology  (ACC) today is releasing a list of “Five Things Physicians and Patients Should Question” in cardiology as part of the Choosing Wisely campaign, led by the ABIM Foundation with eight other medical specialty societies. The list identifies five targeted, evidence-based recommendations that can support physicians and patients in making wise choices about their care.”

Blogfinger editor’s note:  “Stress cardiac imaging” refers to exercise tests, usually on a treadmill, accompanied by imaging methods using nuclear (radio-isotopes) or ultrasound (echocardiography) . “Advanced cardiac imaging” relates mostly to use of CT scans to look for calcium in the arteries or the use of MRI scanners. “Asymptomatic” means without any symptoms. “High risk markers” are indicators of cardiac danger such as strong family history of cardiac deaths, major risk factors such as very high cholesterol, and others.

The “stenting” recommendation is a technical point about emergency stent placements during a heart attack. It means just fix the blockage that is causing the acute condition and don’t stent any other blockages at that time.

The “low risk non-cardiac surgery” reference means that if you are to undergo surgery such as a hernia, you don’t need those high-tech tests as part of a pre-op medical assessment.  Finally, the “echocardiogram” (ultrasound of the heart) recommendation says that routine echoes, e.g. done yearly, are not needed if you have a stable minor valve problem.

“The ACC list details the following five recommendations:

  • Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
  • Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.
  • Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.
  • Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.

Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI).”

Blogfinger Medical Commentary:   Paul Goldfinger, MD, FACC

It’s about time!  Was the profession going to wait until some heavy-handed bureaucrats begin to tell doctors how to practice medicine? The problem of over utilization of testing and therapeutics has been around for some time, although the costs keep going up as the technology improves.

The fee-for-service system has been corrupting, and a fortune could be saved if these abuses could be brought under control. All too often, physicians place their bottom line above the ethics of medicine and the results of scientific trials.

I think most doctors would agree that the current healthcare system needs reform. The controversy is about how to improve healthcare in the US. But, no matter what, the problem of fraud and abuse must be solved.  A good beginning is for doctors themselves, as in the recommendations above,  to insist on practice guidelines that are based on scientific evidence.  Such guidelines have to be flexible enough to not destroy the ability of the doctor to  make decisions with his patients.  They also must be written in a dual format so that doctors and patients can understand. Let’s hope that this is the beginning of a needed reform.

Editor’s Note:  The day after we posted this article, an editorial appeared in the NY Times: “Do You Need That Test?”  If this topic interests you, please read this editorial:       “Do You Need That Test?”

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