As a quick follow up to The Healthy Uninsurable Patient, a few weeks after the blog was posted my daughter received her COBRA (Consolidated Omnibus Budget Reconciliation Act) papers. By this time she had obtained individual health insurance with a high deductible, but a reasonable cost. The COBRA quote came in at $569.04 per month. This is, by the way, more than I pay for my family plan that covered four people. This is also more than she makes in a month. How many 26 year olds can afford $569.04 monthly for health insurance? Of course I have a cadillac plan as an employed physician at a hospital but there are no other options offered. There is not even any information on how she might obtain other coverage included with the papers.
As a side note, it turns out that she was covered by my insurance when she had the CT scan done. Despite the fact that the letter received from Humana stated that her insurance would terminate when she turned 26, she actually was covered until the end of her birth month. She is a post-graduate student and I'm a doctor who deals with insurance issues every day and we still got it wrong. No one at the hospital where she had the tests, including the financial aid people, realized she was still covered. And this is where I work!!! Nor did the upper management in my office or the office staff at the surgeon's office understand that she had continued coverage until June 30 (and the surgeon is employed by the same hospital I am).
Of course payment for the scans will be denied because pre-authorization was not obtained for them and we will have to appeal and cross our fingers. What a mess.
When she saw the premium amount on the COBRA papers my daughter asked, "How can they send this stuff out with a straight face?" Of course we don't know that they do, since we don't know the people at Ceridian in Florida who mailed the papers. More surprising to me is the number of patients in my office who keep a straight face when they say "But there is nothing wrong with our healthcare system. It's the best in the world!" No. It's not.
Saturday, August 11, 2012
Monday, July 30, 2012
Even Non-Kentucky Doctors need to examine Kentucky's Narcotic Bill
Kentucky has had a well-documented problem with narcotic diversion and over-prescribing for some time. In recent years, particularly in the eastern part of the state, prescription drug abuse has flourished and killed an estimated 1000 Kentuckians yearly. In the legislative session this year a "Pill Mill Bill" was passed, aiming to crack down on over-prescribing of schedule II controlled substances and hydrocodone. "Pill Mills" are loosely defined as any clinic or doctor's office where controlled substances are recklessly prescribed. In Kentucky the issue often centered around pain clinics that were not owned by physicians and were operated for the purpose of generating cash, not treating patients[1]. Physician groups lobbied to keep the bill from becoming over-burdening in its effect and not punish legitimate use of prescription pain-killers. HB1 passed and was signed into law on April 24. Most physicians felt a satisfactory compromise had been made that would protect patients without being over-reaching in its effect.
On July 20, 2012, the day the bill was scheduled to take effect, "emergency" regulations were signed into law by Governor Beshear. These ten pdf's worth of regulations went FAR beyond the intent of the legislation. As of this writing physicians must get KASPER reports every time they initially prescribe any schedule II or schedule III drug and some schedule IVs (see below for an explanation of how controlled drugs are classified). KASPER is defined as
How appropriate is it that I ask my 88 year old patient to submit to a urine screen for the hydrocodone she takes some nights for her severe spinal stenosis? Oh, and if you follow the letter of the law, if that drug screen is NEGATIVE I am supposed to stop prescribing the hydrocodone and send her to a drug treatment program! Then again there is the patient who calls in for a couple of Xanax to take for an eight-hour plane ride, usually someone who's been a patient of mine for years. They have to come in first for a COMPLETE physical exam (which their insurance will not pay for unless it been more than a year from the last and it is a two month wait to get a physical in my office) and be counseled regarding use and abuse of narcotics including signing the informed consent. Same for cough medications--so how many doctors will be prescribing cough medications with controlled substances do you think? How much time does the governor think we primary care doctors have?
Despite Governor Beshear's comforting remark "Let me be very clear, if you need a prescription, you will get your medicine", he will not be opening up the governor's mansion to prescribe medication. Last time I checked he didn't have an MD behind his name. In a time when primary care doctors are already over-extended, to enact over-reaching regulations of this magnitude reveals an ignorance of monumental proportions. It is not that it is far easier to say "no" than to spend the time necessary to prescribe the "offending" medications, it is that there are not enough hours in the day to support the implementation of this bill. It's important to understand that these regulations go far beyond the intent of the legislature to stop Pill Mills and over-prescribing of narcotics by physicians. These regulations will reduce the access of necessary controlled substances to ordinary citizens of the state of Kentucky because of the administrative burden placed upon offices already reeling from insurance and other governmental regulations. In addition, they will make the ordinary individual feel like they are requesting "street" drugs, when all they want is relief from their insomnia, their cough, the symptoms of low testosterone, their pain or their anxiety.
Let ME be clear. The 93% of patients in Kentucky that don't have a controlled substance problem will suffer, and suffer unjustly because of the regulations enacted by our governor and attached to this bill.
Defining "Scheduled" Drugs or Controlled Substances:
In 1970 the Controlled Substances Act (CSA) was enacted which placed drugs into categories based on their abuse potential. There are five "schedules"
Schedule I
-high potential for abuse and no accepted medical use for treatment in the US. Instances include heroin, marijuana, or LSD
Schedule II
-high potential for abuse. Patient must have a written paper script to fill. Cannot be refilled by phone. Instances include morphine, methadone, Adderal, or cocaine
Schedule III
-potential for abuse is less. Instances include combination products with hydrocodone such as Vicodan, codeine, or testosterone.
Schedule IV
-potential for abuse is lower than Schedule III drugs. Instances include valium, ambien and xanax. Tramadol is NOT a scheduled drug under the CSA Act and is only considered controlled in a minority of states, including KY.
Schedule V
-This schedule primarily contains combination products containing very limited amounts of narcotics used for cough suppression or diarrheal control.
References
1. http://www.kentucky.com/2012/02/01/2051727/beshear-said-shutting-pill-mills.html
2. http://www.deadiversion.usdoj.gov/schedules/index.html
This blog post was updated on July 31, 2012 to better explain the schedule of controlled substances as well as clear up grammar mistakes in the body of the blog. The opinions and content were not appreciably affected.
It was further updated on September 10, 2012 to update the fact that 93% of patients DON'T have a controlled substance problem.
On July 20, 2012, the day the bill was scheduled to take effect, "emergency" regulations were signed into law by Governor Beshear. These ten pdf's worth of regulations went FAR beyond the intent of the legislation. As of this writing physicians must get KASPER reports every time they initially prescribe any schedule II or schedule III drug and some schedule IVs (see below for an explanation of how controlled drugs are classified). KASPER is defined as
"The Kentucky All Schedule Prescription Electronic Reporting System (KASPER) tracks controlled substance prescriptions dispensed within the state. A KASPER report shows all scheduled prescriptions for an individual over a specified time period, the prescriber and the dispenser."This includes ADHD stimulants in adults, testosterone, and Ambien, tramadol, alprazolam, lorazepam, clonazepam, diazepam, soma, Librium, and phentermine. Patients must see their physician MONTHLY until the physician determines that this is a medication that they should remain on. This must be repeated EVERY THREE MONTHS for as long as the patient is on the drug. In addition we must discuss and have the patient sign an "informed consent". This covers their understanding that the drugs are addictive, reminds them to stop the drug when they no longer have the problem they are taking it for, and how to destroy the medications they do not use. After the initial three months the physician must do random drug urine screens on ALL patients using these medications, discuss if there has been any history of drug abuse in any first degree relative or themselves, ask if the patient has had any legal problems with drug abuse and revisit the issue every three months ad infinitum.
How appropriate is it that I ask my 88 year old patient to submit to a urine screen for the hydrocodone she takes some nights for her severe spinal stenosis? Oh, and if you follow the letter of the law, if that drug screen is NEGATIVE I am supposed to stop prescribing the hydrocodone and send her to a drug treatment program! Then again there is the patient who calls in for a couple of Xanax to take for an eight-hour plane ride, usually someone who's been a patient of mine for years. They have to come in first for a COMPLETE physical exam (which their insurance will not pay for unless it been more than a year from the last and it is a two month wait to get a physical in my office) and be counseled regarding use and abuse of narcotics including signing the informed consent. Same for cough medications--so how many doctors will be prescribing cough medications with controlled substances do you think? How much time does the governor think we primary care doctors have?
Despite Governor Beshear's comforting remark "Let me be very clear, if you need a prescription, you will get your medicine", he will not be opening up the governor's mansion to prescribe medication. Last time I checked he didn't have an MD behind his name. In a time when primary care doctors are already over-extended, to enact over-reaching regulations of this magnitude reveals an ignorance of monumental proportions. It is not that it is far easier to say "no" than to spend the time necessary to prescribe the "offending" medications, it is that there are not enough hours in the day to support the implementation of this bill. It's important to understand that these regulations go far beyond the intent of the legislature to stop Pill Mills and over-prescribing of narcotics by physicians. These regulations will reduce the access of necessary controlled substances to ordinary citizens of the state of Kentucky because of the administrative burden placed upon offices already reeling from insurance and other governmental regulations. In addition, they will make the ordinary individual feel like they are requesting "street" drugs, when all they want is relief from their insomnia, their cough, the symptoms of low testosterone, their pain or their anxiety.
Let ME be clear. The 93% of patients in Kentucky that don't have a controlled substance problem will suffer, and suffer unjustly because of the regulations enacted by our governor and attached to this bill.
Defining "Scheduled" Drugs or Controlled Substances:
In 1970 the Controlled Substances Act (CSA) was enacted which placed drugs into categories based on their abuse potential. There are five "schedules"
Schedule I
-high potential for abuse and no accepted medical use for treatment in the US. Instances include heroin, marijuana, or LSD
Schedule II
-high potential for abuse. Patient must have a written paper script to fill. Cannot be refilled by phone. Instances include morphine, methadone, Adderal, or cocaine
Schedule III
-potential for abuse is less. Instances include combination products with hydrocodone such as Vicodan, codeine, or testosterone.
Schedule IV
-potential for abuse is lower than Schedule III drugs. Instances include valium, ambien and xanax. Tramadol is NOT a scheduled drug under the CSA Act and is only considered controlled in a minority of states, including KY.
Schedule V
-This schedule primarily contains combination products containing very limited amounts of narcotics used for cough suppression or diarrheal control.
References
1. http://www.kentucky.com/2012/02/01/2051727/beshear-said-shutting-pill-mills.html
2. http://www.deadiversion.usdoj.gov/schedules/index.html
This blog post was updated on July 31, 2012 to better explain the schedule of controlled substances as well as clear up grammar mistakes in the body of the blog. The opinions and content were not appreciably affected.
It was further updated on September 10, 2012 to update the fact that 93% of patients DON'T have a controlled substance problem.
Sunday, July 15, 2012
The Need to Blame the Doctor, not the System
Maureen Dowd wrote a thoughtful and thought-provoking article in the New York Times this morning entitled "The Boy Who Wanted to Fly". I had read about the incident in a twitter-linked article earlier in the week and my heart ached for everyone involved--the boy, the parents, the pediatrician, the ER docs and the staff treating him at the hospital. I know from professional experience how gut-wrenching this outcome is to the doctors and staff involved. As a parent I prefer not to imagine what the personal experience would be. It was hard enough to have stood beside friends as they moved through it.
Many of the comments below the article demonize the physicians involved in the care of this boy. That is an easy thing to do and seems to be a particularly American way of approaching a problem--find someone to blame and sue them. Unfortunately, this will do nothing to fix what is an increasingly common problem in our healthcare system today.
I don't know the specifics of what happened in this case. On the surface of it, the article and remarks about it emphasize many of the issues of our broken healthcare system. The comments engendered begin with 'hard-hearted doctors" and "sue the jerks". Perhaps the most thoughtful was the comment by Infectious Disease specialist Dr. Jonathan Rosenthal who said: "The average physician will never see a case of florid Group A Streptococcal septic shock such as this one in her entire career. One of the reasons these rare cases can be so lethal is that is can be enormously difficult to pick them out from among 10000 cases of viral illness in a Pediatric ER. Herculean efforts are made every day not to miss early sepsis. We can learn from cases like this but not if we are distracted by looking for the person to blame. This poor child was seen by a number of physicians - were they all incompetent?"
As a primary care physician some of my thoughts are: How busy was the pediatrician? How busy was the ER? Did they have the time and experience to pick up on those "soft signs" of sepsis that Sully Sullenberger alluded to? As an aviation safety expert he understands the importance of fixing the SYSTEM that is causing the problem, rather than placing blame on the individuals involved.
Patients live in a world where physicians are pushed to see more and more of them to pay the bills; where technology substitutes for stopping and really "seeing" a patient as more than a disease state; where the patient is seen only as a dollar sign by the healthcare administrators, insurance executives, employers, lawyers and politicians who crowd into the examining room as if they had a sacred right to be there; and where time, the most important commodity for good patient care, is stripped from those on the front lines because it is not valued highly by their own peers.
This case should be a rallying cry for patients (and we are all patients) to fix a badly broken, fragmented healthcare system where volume and technology substitute for care. Since this involves a political fix from a system equally broken and fragmented, a fix that must involve compromise from both sides of the aisle, I fear for the future health of my patients and my profession.
Many of the comments below the article demonize the physicians involved in the care of this boy. That is an easy thing to do and seems to be a particularly American way of approaching a problem--find someone to blame and sue them. Unfortunately, this will do nothing to fix what is an increasingly common problem in our healthcare system today.
I don't know the specifics of what happened in this case. On the surface of it, the article and remarks about it emphasize many of the issues of our broken healthcare system. The comments engendered begin with 'hard-hearted doctors" and "sue the jerks". Perhaps the most thoughtful was the comment by Infectious Disease specialist Dr. Jonathan Rosenthal who said: "The average physician will never see a case of florid Group A Streptococcal septic shock such as this one in her entire career. One of the reasons these rare cases can be so lethal is that is can be enormously difficult to pick them out from among 10000 cases of viral illness in a Pediatric ER. Herculean efforts are made every day not to miss early sepsis. We can learn from cases like this but not if we are distracted by looking for the person to blame. This poor child was seen by a number of physicians - were they all incompetent?"
As a primary care physician some of my thoughts are: How busy was the pediatrician? How busy was the ER? Did they have the time and experience to pick up on those "soft signs" of sepsis that Sully Sullenberger alluded to? As an aviation safety expert he understands the importance of fixing the SYSTEM that is causing the problem, rather than placing blame on the individuals involved.
Patients live in a world where physicians are pushed to see more and more of them to pay the bills; where technology substitutes for stopping and really "seeing" a patient as more than a disease state; where the patient is seen only as a dollar sign by the healthcare administrators, insurance executives, employers, lawyers and politicians who crowd into the examining room as if they had a sacred right to be there; and where time, the most important commodity for good patient care, is stripped from those on the front lines because it is not valued highly by their own peers.
This case should be a rallying cry for patients (and we are all patients) to fix a badly broken, fragmented healthcare system where volume and technology substitute for care. Since this involves a political fix from a system equally broken and fragmented, a fix that must involve compromise from both sides of the aisle, I fear for the future health of my patients and my profession.
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