Medicine Magic Lamp

My real estate agent voice was trembling on the other side of the line. I was expected to walk through the house with the buyer and show him few things. I called her because I forgot my keys to the house. Luckily she was in the neighborhood. She said that she would be on her way. I couldn’t fathom the reason behind her shaking voice until she uttered: “Did you know that ‘the doctor’ shot himself?!” My first reaction was that of disbelief and shock. It took me a moment to realize what she is really saying.  “He was my daughter’s doctor and she heard from some of her friends. I hope it is not true”, she added. Five days later, and I am still pondering what happened.

I did not know ‘the doctor’ on a personal level but I have seen him in the physicians’ lounge every once in a while. He struck me as a confident nice man. A man that can be successful in whatever he put his mind into. In fact, he had the look of a politician. Our interactions were limited to greetings but sometimes these can be enough to form an opinion about somebody. His piercing blue eyes gave one the feeling of warmth and trust. I learned after his death that he was a fourth generation physician and that his great grandfather established the local clinic in the early 1900’s.

I knew that his practice has been recently in trouble. He made it clear to the community that it will be closing its door this month. He had a strong competition from the other multispecialty clinic in the community over the past few years. His practice ended mainly dependent on a single large health system that did not have his specialty presence in town. However, when that large health system decided to consolidate all their patients and bring their own physicians to town, the doctor practice almost collapsed.

The doctor, God bless his soul, was and is not the only one who is dealing with these issues. Issues that stems out of the efforts to redesign the current health care system. Physicians are constantly under pressure to join patient-centered medical homes, accountable care organizations, coordinated care organizations and others. Otherwise, they risk payment cuts from various insurance agencies and Medicare. Small group practices have to swallow the cost of electronic health records programs, and other various new regulations or risk more cuts.

It appears that all the recent health care reforms and regulations are geared toward consolidating medical practices into bigger systems that has the resources to deal with them. Implementing an electronic health record (EHR) for example come with a price tag of $233,297 for the first year for an average five physician practice according to a recent study. This cost includes hardware and software expenditures and lost productivity during implementation of EHR. Sure there will be improved productivity down the road but there is also the annual cost of maintaining EHR, which is estimated at $17,000 per physician.

This is a big burden that small practices cannot handle easily. But government not only want to implement EHR, it wants physician and health care systems to demonstrate “meaningful use” of EHR. Therefore, EHR system they use has to be a certified to satisfy the rules of meaningful use. On top of that, physicians have to prove it so that they can get some incentives. Meanwhile, they have to take care of patients, deal with the competition and politics de jour.

Government is rubbing medicine magic lamps and the genies are coming out. However, these genies may not grant physicians all their wishes. They have to choose to either ride on the shoulders of these genies or risk being crushed under their giant feet. The ideal solution will be for the physicians to transform into genies and lead the way but they are too busy taking care of patients and the genies are already out. The doctor was busy taking care of his patients and did not have the chance to transform. Rest in peace doctor!

A chief complaint

In the email that I got from the person at our billing department it was explained to me that I couldn’t bill the patient for a follow up visit if he/she has no complaints. She further elucidated that when they have no complaints, I should write the diagnosis as a chief complaint. I follow patients with chronic kidney disease and many of them come to me to monitor their kidney function, blood pressure and to manage risk factors for progression of their disease. Many of them do not complain of anything specific until very late in the course of their disease.

In Medical school and Residency, we learned that a “History and Physical” has a seven essential elements: chief complaint, history of present illness, past medical history, social and family history, physical examination, review of laboratory and imaging findings, and an assessment and plan. The chief complaint, we were told, is better described using the same words used by the patient. A follow up note, on the other hand, has four elements: subjective, objective, assessment and plan. I do not recall ever being told to include the patient diagnosis in the chief complaint so that I can bill him. In fact, we never received any education about billing patients!

Yesterday, I received a copy of one of my colleagues note. It started with the chief complaint: “I am here for a postoperative global assessment!” While, I was pretty sure that the patient did not say that, I knew exactly what it meant. It is the only way my colleague can get paid for his services. This is our modern day Medicine. Physicians have to document their “services” in a way that appease bureaucrats in insurance companies and Medicare and not conform to their trainings.

Instead of compassionate care and sound clinical judgment, we are now witnessing the gradual transformation of Medicine into lines of services that are gradually falling into the abyss of hardhearted automation. This automation has to comply with regulations, paperwork requirements and guidelines. All while maintaining a great score on the patient satisfaction surveys to sustain the physician salary without performance cuts.

The state of current Medicine has a chief complaint and it is not about how to bill better. Medicine is sick .The history of its present illness is that physicians have left the field to others to tell them what to do and how to do it best. At this time, it appears to be a hopeless case. Its prognosis is poor! I guess the chief complaint and the diagnosis are the same: Medicine has a terminal illness.

‘Prior Authorize’ This!

Do you still believe that bundling your phone, cable, and Internet services save you money? You usually sign a contract for two years only to realize after few months that the prices for your services have dropped significantly. Well, The Center of Medicare and Medicaid Services (CMS) like to bundle. Few years ago, CMS decided to try to save on it massive payments for dialysis and dialysis-related medications by bundling all dialysis services for a patient in one payment. After lobbying and dilution, it was successful in implementing some kind of ‘dialysis bundle’.

In the decade prior to the bundle, many dialysis companies profited from several necessary medications that they started giving to patients on dialysis. These included anemia medications and drugs that help combat kidney disease-related bone disease. They buy in bulk at a discounted price and charge the patients the individual price in addition to personnel fees. It was a broken system and the fat cow was being milked dry.

Calcitriol, which is an active vitamin D that is usually produced by the healthy kidneys, was one of these medications. It has been on the market since 1982 but more recently many of it analogues has become available and used widely in dialysis patients. In addition, the increase emphasis on bone health in kidney patients prior to dialysis has lead to increasing its oral use in these patients. However, the tsunami of the bundle washed Calcitriol away from the non-dialysis patients. Suddenly, every time I write a prescription for this drug my office get a two-page form requesting a ‘prior authorization’.

My Medical Assistant has to fill a form that proves that the patient is not a dialysis patient and, therefore, this medication should not be part of any bundle. Many of these forms arrive to my office every day and my Assistant fill them, and then I review and sign them. It is the usual unintended bad consequence of good intentions. Needless to say, CMS is discovering that the two-year contract was really not fair.

We spend valuable time taking care of these forms and many many other forms instead of rooming patients and taking care of them. Everyday, some insurance company decides that a ‘prior authorization’ is required for a drug that a patient has been taking for many years. I think I am going to charge insurance companies $15 for each ‘prior authorization’ form we fill. I bet they will request a ‘prior authorization’ for that!

The story of Colchicine:

An Epic American Health Care Conundrum

“This medication is not only therapeutic, it's also diagnostic!” These were the words of my rheumatology professor during my Internal Medicine Residency describing one of the oldest medications. “If the patient arthritic pain resolves rapidly after taking colchicine then he definitely has gout. This drug is also very cheap!” he added. This medication, which has been on the market since the sixties, is no longer available except in one form that costs at least $5 per pill, if you are lucky.

The derivative of the seeds of the autumn crocus has some known side effects and drug interactions. However, it has few problems because not all its side effects were reported adequately. The major problem that Colchicine had, however, was that its production started before the FDA was created. This put it on the list of drugs that are “unapproved” by the reputable agency.

In 2006, the FDA decided to go after old drugs that it had never approved. The “Unapproved Drugs Initiative” involved testing the safety of these old drugs by certain pharmaceutical companies. In exchange, the testing company gets market exclusivity for 3 years. And so, URL Pharma won the market for the brand-name colchicine (Colcrys) in 2009 and suddenly in 2010, generic colchicine became no longer available for US patients.

A drug that used to cost $3 for 30 pills now cost American patients at least $169.99 for the same amount of tablets.  Many of my patients report that they have to pay more than $200 for the bottle and many can’t afford it. This is the story of the American health care system in the twenty first century: Increasing costs by not only inventing new complex therapeutic devices and chemicals that barely increase meaningful patient survival but also by targeting old well known medications with studies that only prove their well known side effects.

In the era when we talk about Medicare going bankrupt and the Affordable Care Act controversies, allowing lobbyists, pharmaceutical companies, and insurance companies to dictate how should physician care for their patients is only going to lead to more waste and ballooning health care expenses. Almost every politician, regardless of party affiliation, is responsible for this epic failure. Those who protect the gains of pharmaceutical companies with the argument of protecting the free market and those who want to extend the health care coverage to the vast majority of American without addressing these core problems.

The story of Colchicine is the story of every poor patient who is passing on paying for his medications to pay for his upside-down mortgage, for his car loan and to put food on the table. It is story of every American who would rather fill his Vicodin to numb his pain and suffering than filling his expensive medications that can treat the cause of his illness. It is the story of my residency professor who when he heard the news decided to retire because this is not why he wanted to be a physician.

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