Bureaucracy: A Leading Contributor to the Death of Private Practice

One of my practice’s head nurses, who usually have a high tolerance for frustration, finally showed some exasperation. It seems that the she had just spent 15 minutes on the phone explaining to a representative from Express Scripts, why one of our patients needed to take Pradaxa, a new anti-coagulant, rather than Warfarin. The aggravation grew from the assertion by the faceless voice on the phone telling her that this medication could be prescribed only for "nonvalvular atrial fibrillation." Here’s the rub: All of our prescriptions for Pradaxa read "for nonvalvular atrial fibrillation" to prevent this sort of red tape. The agent just hadn’t bothered to read that.

Far from being unusual, this kind of scenario plays out daily in our office, and those of thousands of physicians across the country. Indeed, I would assert that it is rapidly becoming the rule, and not the exception. It seems that every decision we make as doctors, from test ordering to prescription writing, is questioned or blocked by a bureaucrat, allegedly on behalf of the patient to keep medical care "cost-effective." This nifty euphemism really means less expense and more profit for the pharmacy or radiology "benefits manager" and/or insurance company. It is certainly not "cost-effective" for either the doctor or the patient.

Our professional decisions are under assault by hundreds of delaying forms and phone call approvals. This adds to our "overhead" with no increase in reimbursement. Out of sheer frustration, and lack of staffing to battle this leviathan of corporate officialdom, we often give up. They win, and the patient looses.

JMR, another one of my patients with end-stage heart and lung disease is on round-the-clock oxygen. On his last visit he showed me a form from his oxygen supplier: "Respiratory Pharmacy." It said, "Take this sheet with you to ALL doctor's visits."

The letter then stated, "Your doctor(s) must write that you must use ... the oxygen ...in your progress notes. If your doctor fails to document your 'continued use and need' of these items, you will not be able to get the service, supplies, or medications."

It goes on further to say "Medicare will not pay for your …oxygen …if your doctor does not write that you 'continue to use and need' this item." There is zero likelihood that JMR will not need oxygen.

Pharmacy benefits managers (or PBMs) seem to troll the price sheets daily for deals on generic drugs. So this week, they might approve an ace-inhibitor for the treatment of hypertension, and not an ace-receptor blocker, and then next month, they may allow the latter. All of this of course entails phone calls from distressed patients, and more forms to complete. As a direct consequence, avoidable delays in medication administration, and missed doses, are all too common.

Changes in commercial health insurance policies are not immune either. One of my wife’s medications was questioned because she hadn’t tried a generic instead. We went through this all last year - alas, with a different insurer.

Medicare Part D has spurred another thorn in the side of physicians’ offices. They change yearly the medications they cover and don’t. So the same patient, who has done well on the same medication, must have more forms completed every January that were justified and finally approved only one year before.

These are more ways that the private practice of medicine will die –– not death by a thousand cuts –– but death by a thousand forms and phone calls.

Find out more about David M. Mokotoff and our other Practice Notes bloggers.