Merigian Studios


Adapt Not Manage

Adapt Not Manage

It has been an unusual week. As I sit writing this blog, there is torrential rain coming down from the heavens causing one of my skylights to leak. Just less than eleven days ago, I was shoveling ice on our parking lot to clear a path for our patients to walk after they parked their ice capped cars. I still have muscle soreness from that five hour adventure. The rain has all but melted the remaining islands of ice on my driveway and in my yard. Nature has a way of adjusting its environment to the demands of its diverse global ecosystems. It seems unpredictable and random because it is. So is the onset of disease in most cases.

Frustrating to me is the current accepted medical axiom that healthcare providers can manage a disease. There is an entire field of healthcare workers dedicated to disease management. More irritating than an incessant itchy rash is medical insurance and pharmacy benefit management plans embracing step therapy based on standardized protocols that medical experts created in their own images. As new information floods the medical and basic science research journals, these archaic step therapies get in the way of providing safe, effective cutting edge care to the majority of our US patient population. It is not uncommon for me to order an MRI or some other test and have to speak to a case review physician working for an insurance company who is no longer practicing medicine. His or her sole purpose is to review my medical logic for either ordering an imaging procedure or prescribing a drug and applying my logic to their employer's protocol.

This past week, a patient revealed that her left side of neck was swollen, she could feel an enlargement or mass in her neck and she could not swallow her medications. She also had enlarged lymph nodes in her left arm pit. To me, there was no choice. I had to get a soft tissue CT scan of her neck with contrast. After ordering the test, the insurance company would not approve it until I spoke with their medical officer. Mean while, the patient could not eat or drink anything, felt weak and she was worried about having new onset cancer. I spoke to the peer-to-peer physician. He was a jolly old fellow. He revealed to me that he was a retired family practice physician after spending twenty five grueling years in the trenches of primary care practice in upstate New York. I thought to myself, Twenty-five years? I got 30 years in and plan on 15 more. Their medical director had a lot less healthcare experience than I.

He read me the medical insurance company's criteria for an accepted reason for performing a soft tissue CT scan of the neck and my patient did not meet their criteria. After I explained the situation, her signs and symptoms and her fears about cancer, he decided to approve the scan. To him, my Bayesian logic was without flaw and their insurance criteria was not in accord with sound medical practice. It took about thirty minutes away from patient care time after he called. Ironically, the hospital's parking lot where she was supposed to have the scan was iced over and the hospital staff recommended she wait until the ice had melted before she drove to the hospital for the test. So the patient rescheduled the scan. She still cannot swallow her medications or eat and her neck is still swollen. There was a cost for the physician reviewer to intervene needlessly as well as a cost to the patient I was seeing at the time of his call. How is this activity saving anyone any money or making the system more effective?

In the case of pharmacy benefit management (PBM) plans, the leaders in the field have instituted step therapy protocols. These are protocols that steer physicians to a certain pharmaceutical therapeutic adventure after they have prescribed a medicine considered too expensive by the administrators of the PBM. This action takes place at the pharmacy, the pharmacist will call the physician and advise him or her that their prescription is out of accord with the PBM plan's protocols. The pharmacist then recommends the alternate options the PBM has approved for the patient void of any physician input on the subject. Sometimes the PBM will have an override mechanism. You probably guessed what it is, a peer to peer review of the prescribing physician's treatment plan with the PBM's medical expert (who may be a Pharm.D., not an M.D.). Sometimes the PBM sends a fax to physician's office with the criteria related to their step approach.

The PBM company will not stop the patient from getting the drug the physician prescribed, they will just insist that an alternate therapy must be tried and failed before they will consider paying for any other drug. That means more physician visits if the drug fails, more out of pocket expense for co-pays, ultimately the patient may need the more expensive drug. In addition, the patient may be at risk for a medical emergency if the PBM's drug is ineffective. Then there is the inconvenience to both the physician and the patient. But the primary mission of the PBM plan is upheld: charge a fee for a service that might save some of the insurance company's money at everyone else's loss.

One cannot manage a disease no matter how intellectually gifted they are. The onset of a disease is a random event. It is not a God thing, it is a human thing. In my past worldview of disease, I thought every disease onset had a reason. Over the years, I have discovered that my past worldview was wrong. So I changed it. Being that disease is a random event, there are lifestyle circumstances that make the random event more likely to occur. If you never drive or ride in a car, you will never have a car accident. The more often you drive your car, the more likely you will have an accident even if you are a safe and vigilant driver. People who drive recklessly have a greater risk of experiencing a car accident. Regardless, a car accident is a random encounter that may have profound effects on the drivers and passengers riding in the vehicles that collided.
That is disease: a medical car accident. Despite all of the traffic management and law enforcement systems, automobile accidents happen fairly frequently in Memphis. Despite all of the opinions and scientific research about what to do to be healthy, disease seems to be on the rise. I see new cases of common and rare diseases every day in patients who care about their health. They are usually shocked that they have an illness because they have been so healthy. But whose healthy have they been? Diseases are not physician or case worker manageable, they are only treatable. A patient experiencing a disease must adapt to the disease. And most patients have the capacity to adapt, but they lack the will. Smart, careful drivers adapt their driving style to the conditions on the road. Smart, diligent patients adapt their life style to the conditions affecting their body. Medications help the patient adapt, but medications do not manage the disease nor do they cure the disease. The patient must educate themselves about their disease, much more than the physician knows, and adapt to its effects on their body. If not, the disease will advance and the patient will succumb to it in all of its manifestations.

A blind physician cannot see your illness much less manage it. Most modern day physicians are blind to the infirm. Adapt to your illness and stop letting standardized protocol driven doctors manage your disease.

Posted by Amanda Sanders at 9:00 AM
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