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What happens when the medical industry puts an incredible amount of pressure on a practitioner group to generate money, to follow standard protocols, to stop prescribing pain medications to patients in pain, to pre-cert every imaging test, to pre-cert medications, to type data into an electronic medical record, and to deliver high-quality care to patients in a timely manner (three to five minute intervals) ? Two things happen to them. One is practitioner burn-out. The second is physician suicide.

There is this growing crisis of physician burn-out, and it's getting worse every day. Patients do not recognize the amount of red tape and bureaucracy that the hospitals (HOSP), medical insurance companies (MIC), and pharmacy benefit plans (PBM) have created through complex algorithms to put up barriers to high-quality patient care. Each time a physician prescribes a drug for a medical condition, a pharmacy benefit plan is activated at the pharmacy to determine if the drug is on their common formulary. The term accepted means the PBM will reimburse the patient or pay the pharmacy a suitable amount of money to cover the drug’s retail cost as long as the patient makes good on their copay at the window. These PBMs are operated by pharmacists and accountants who discovered that they could make money on restricting patient access to certain medications or steering patients to certain brands. Some researchers in healthcare have shown that these PBMs make about ninety dollars per prescription when it is all said and done.

PBMs contract with academic medical experts to create step approaches to pharmaceutical disease management integrated with FDA indications based on diagnoses. These protocols are held in strict confidence and are considered proprietary in the drug delivery industry. The PBM introduces physicians to these protocols after writing a prescription, and the patient presents it to a retail pharmacy. If the medication is on the PBMs’ formulary, the PBM approves the medicine in the blink of an eye. If not, the pharmacist tells the patient that the physician must complete a prior authorization form before the PBM approves the medication. The pharmacist faxes the PBM request form to the physician office and the approval process begins. The method can take a few minutes or a few months depending on the PBM and the medical treatment of the illness in question.

The bottom line is that it takes physician brain power to get the prescribed medication approved. PBMs are clever beyond belief. They do not care about the patient’s wellbeing. They care about profits. The majority of medical illnesses do not have an FDA approved medication. Therefore, physicians write the majority of prescriptions for off-label uses. The light should come on now. Anyone can see that the PBM can disapprove the majority of medications because most of them are not FDA approved for the treatment of an illness. If there is a diagnosis or disease that the FDA has approved drugs for, the PBMs create tiered approaches for treatment. Physicians are given alternates to choose from. Most times these medications are not sufficient even though they were approved many years ago. The PBMs require a month of failed treatment before they will pay for a second-tier drug. If that drug trial fails, they will them pay for a third-tier drug. It may take several months to get to an effective medication by playing these pharmaceutical games. Not only does the patient agonize from their illness, the physicians or their staffs also struggle. If the patient suffers a complication while on the inferior drug, the responsibility lies squarely on the physician, not the PBM. The stress of juggling hundreds of patients in a busy practice can be overwhelming. If a physician is conflict adverse, they will seldom fight for their patient, demanding the PBM approve the proper course of therapy. It’s a fight.

Insurance carriers have adopted similar behaviors when it comes to requesting imaging and expensive medical testing. Nurse reviewers examine every MRI request without any regard to a medical case as a whole. The reviewer does not have a copy of the entire medical record. Many times, the medical history does not contain the specific wording the examiner is looking for which are buzz words in their protocols. Most often, the element of time does not permit physicians to record a description of the patient illness in minute detail. Some physicians pay scribes to enter medical history and physical exam results. The reporters are often college students looking to get into medical school. They do not have the education to record pertinent positives and negatives regardless of their skill sets. I have seen medical records created by scribes that have glaring errors and no corrections by the physician for whom they were scribing.

I have had hundreds of conversations with insurance paid consultants as peer to peer discussions about test and imaging requests. I can remember a single-digit number of times that I did not get an approval and confirmation number for the imaging test requested. Other physicians I know do not take advantage of peer to peer review since they are offended by the denials of their requests; they believe peer to peer is a waste of time. The result is an increase in profit for the insurance company and poor-quality care for the patient. Medical insurance companies will never defend any physician in a failure to diagnose lawsuit. They take the position that they do not dictate the standard of care. The time and effort needed to care for a patient properly are beyond the reach of most physicians.

Hospitals have created physician staffs by buying practices and contracting directly with physicians. Once a hospital owns a physician, the administrators have control of the physician’s clinical schedule and office personnel. The physician must abide by the staff bylaws which may or may not be in a patient’s best interests. Physicians refer to other hospital-owned physicians, even if they know that the best specialist for their case is outside of the hospital’s physician pool. As a member of the hospital staff, physicians must comply with the hospital's demands which include committee memberships, grand rounds attendance, and monthly hospital staff meetings. The politics of a hospital are as bad as church politics. The staff creates a pecking order and those on the bottom tier are subject to many indiscretions. The hospital does not create levels by quality-care indicators; they create them by the amount of cash generated per physician which includes admission rates per patient population, test ordering, and clinical use of the outpatient programs such as physical rehabilitation, occupational rehabilitation, cardiac rehabilitation, stroke rehabilitation, and speech therapy are a few revenue-generating services as well as outpatient infusion therapy. Services that were once provided by physician offices are transferred to the hospital since they can charge more for the services.

Medical insurers are beginning not to honor physician testing orders if the physician is not a member of their PPO, even though the insurer offers an out-of-network benefit. Hospitals are refusing to perform testing on patients unless they have a physician on their staff examine the patient before the service, even if the medical insurer has provided approval and confirmation of the testing. Added to the mix of stressors is the Medical Board, a group of handpicked physicians by the Governor of the State, who oversees medical licensure based on the State’s agenda. The opioid crisis has allowed the Governor and State legislators to create a database on opioid prescriptions. They have implemented three versions of State laws concerning opiate prescriptive habits, all of which have been different and cumbersome to both patients suffering from pain and physicians trying to keep an oath to treat suffering. I get emails every week from the State government insisting that I look at the data on my patients in the database and review each case for possible modifications in their therapy. I have worked hard to comply and will continue to do so. The sad fact is that heroin overdoses are up; people are dying more than ever from illicit drug abuse. The Federal government is requesting States to reopen methadone treatment centers which were unsuccessful in the seventies and eighties.

I suspect that we will witness the State justifying more oversight in physician practice at the whim of lobbyists who want to ensure the free medical market reimburses their company’s investments in healthcare. I believe the State will create clinical practice protocols for treating depression since that leads some patients to drug abuse. I think anyone can see the spokes that attach to the hub of the wheel.

If anyone wonders about the climbing burn-out and suicide rates of physicians, think again. Doctors are overly stressed by an industry that sees physicians as service providers much the same way as the assembly line workers in the automotive business. If I let my mind free, I can see that physicians are health service providers in the first order. In New York City, eight resident physicians have committed suicide by jumping off of hospital rooftops in front of windows of the inpatient rooms. The hospital administrators have taken the position “next man up.” The hospital administrators are not analyzing the patient care system in their hospitals to see if there is anything they can do to mitigate the stress of practicing hospital-based medicine. The residents are under tremendous pressure to provide services to so many taskmasters; medical school funding comes from hospital and outpatient medical care, not the federal dollar as it once did. Foreign physicians were replacing these American graduates on a moments notice.

The government officials I’ve spoken to relate that their answer to the medical practitioner crisis is to have software companies (Microsoft) develop artificial intelligence algorithms to replace physicians. No burnout, no suicide if Watson (IBM) provides care for the infirm. If you think this concept is far-fetched, think again when you are speaking into a microphone at a drive-through office which includes a dispensary for your medicines and a robot to perform your surgeries.

Take a moment to contemplate the future of healthcare as each component in the system tries to squeeze every bit of profit out of the industry. Look at your parents. Look at your children. Be worried. The practice of medicine is going to change rapidly during the next generation. The costs of medical school to train physicians are too expensive to continue. Be worried. Only the mongoose can smell the breath of the snake.

And, they are all snakes!

Doc

 

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