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DROWNING IN FORMATION
Mary G. Barry, MD
T
Louisville Medicine Editor
[email protected]
here are lots of reasons that few
residents are choosing the office
practice of Internal Medicine as a
career (some would call it a vocation; others might say a straitjacket). But as a betting
woman I would nominate form-filling-out
as the top deterrent. We have spent months
of our limited lifespans staring hatefully at
the stacks of preauthorization forms, insurance forms, disability forms, home health
forms, Face to Face encounter forms, and
diabetic everything forms – shoes, strips,
lancets, drugs. We must produce waiver
forms, FMLA forms, “Fix my power outage
first” forms, housing assistance forms, and
DME requisitions for DME of every stripe.
We are expert at notes for work, Boy Scout
and Girl Scout leader forms, camp forms,
Dept. of Transportation forms, disabled
driver forms, and of course – the one so
complex we require help from formal evaluations by PT and OT – the power wheelchair
form, that seven page monster. Every Medicare Advantage annual visit comes with a
five page form that the office should have
mailed the patient first (hmmm…..not in
the habit of yet, at least where I live) and
without which the innocent patient will be
billed more, therefore leaving it up to us,
the patient’s final advocate, to recognize and
remedy during the office visit. I’d say the
advantage part there is at least the patients
share in the pain of form-filling-out, as (frequently in a fasting state) they wrestle with
data which is generally either already in the
EMR or unnecessary and impertinent. If we
are trying to identify the frail or depressed
elder, why don’t we ask detailed questions
about walking, stair-climbing, house and
yard chores, and falls? We just need one or
two questions about morale and outlook –
not twelve.
Pharmacy benefit managers like the big
90 day places (Caremark, Express Scripts,
Rightsource etc.) get it in the neck from
doctors and patients because of their intransigence, and that is not entirely fair.
The patient’s individual plan formularies
are set by their insurance companies, and
not by the likes of Medco. But we who fill
out and patients who want costly or out of
favor meds that actually agree with them
AND work, blame the messenger. After all,
they’re the ones who, after we fax the completed form three times in a week, never
getting any reply, tell us that the 48 hour
limit has expired, and that we have to start
all over for the same medication. They’re
the ones who send us a form that serves
only to request the real form, but of course
we must do both. They’re the ones who refuse all access to any physician, with whom
we’d have some hope of having a reasonable
discourse, and give us only some functionary or, occasionally, a nurse, who still must
read from a pre-ordained script and God
forbid if our Answer A does not exactly fit
the desired Slot B.
Certain idiocies are common to all insurance companies. There is no sensible reason
why a patient proven to be intolerant to or
resistant to the effect of cheap medicines
A,B, and C in 2009 should be forced to buy
them all over again now, in sequence, to satisfy the demand that “Medication such and
such has been tried in the last 18 months.”
Their insistence on trying cheaper drugs
that may harm the patient – but have not
been proven to do so because we have refused to try them, since we like NOT to
harm the patient (for instance ARBs in the
patient with angioedema on ACE inhibitors)
– leads to bitter acrimony and acid letters
from us that say, in effect, are you out of
your minds? Because if you are, here is the
patient’s attorney’s contact info.
Because of proposed changes, all of this
is about to hit home harder with our Psychiatry and Rheumatology colleagues. They
already fill out forms even for cheap generic
medications, as we do, since CMS in its wisdom has decreed that no one over 65 ever
may take any sedative or hypnotic, as it will
surely kill them dead on the spot; hence the
forms. At least for Medicare patients, since
2006 however psychiatrists have enjoyed
the protected status of the six specialist
classes of drugs on the Medicare Part D
formulary. Antidepressants, antipsychotics,
antineoplastics, anticonvulsants, antiretrovirals, and immunosuppressants so far
have “all or substantially all” been included
in every plan. This makes perfect sense to
me: people’s brains and tumors and psyches
and immune systems vary hugely, as do the
diseases that attack them, and both research
and painstaking trial and error in the indi(continued on page 34)
March 2014
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