You know it never died. But in the health policy world, it is so easy to get caught up in the lingo used at conferences and in journals — Accountable Care Organizations, Pay-For-Performance, Population Health Management — that it’s easy to delude yourself into thinking that things have actually improved for the doctors and patients. So, it is valuable to get kicked back into reality by an actual practicing physician who takes the time to put pen to paper and write about her experience. Here’s Dr. Danielle Ofri:
The letter in my hand concerned one of my patients, Mr. V., who suffers from stubborn hypertension. His chart is a veritable tome, documenting the years of effort it took to find the combination of four different blood-pressure medications that controls his hypertension without upsetting his diabetes, kidney disease and valvular heart disease or making his life miserable from side effects. We’ve been on stable ground for a few years now, a state neither of us takes for granted.
But Mr. V. had changed insurance companies, and now one of his medications required a prior authorization. The last thing I wanted was for him to be turned away at his pharmacy and have his blood pressure spiral out of control, so I called right away to sort things out.
Twenty minutes of phone tree later, I discovered that the problem was that I had exceeded a pill limit for one of his medications. Mr. V. needed to take 90 of those pills each month for the high dosage that his blood pressure required. I patiently explained this to the customer-care representative.
Equally patiently, she told me that 45 pills a month was the maximum allowed for this particular medication.
Three more phone trees and three more customer-care representatives later, my patience was flagging. Apparently a request for 90 pills was flummoxing the system. Representative No. 4 asked me to list all the blood-pressure medications that Mr. V. had been on in the past, including dates of initiation and relevant lab values, a request of epic proportions in his case.
The representative went down her checklist. “Would taking 45 pills per month instead of 90 pills adversely affect Mr. V.’s health?” she asked.
At first I thought she was joking. “Well,” I replied, “it would probably make his blood pressure shoot up in the second half of the month.”
This article could have been written ten or twenty years ago (and back then, more of the medicines would have been patented, and therefore more expensive). Despite all the new care models trumpeted by the academic and political leaders, physicians’ professional lives still consists of too much time navigating insurers’ bureaucracies. Whenever the customer (patient) is a different party than the payer (insurer) there will be some friction in the system. But the U.S. has made it worse by giving employers monopoly control of most people’s healthcare dollars. This system has two negative characteristics that Dr. Ofri’s story demonstrates:
- “Mr. V. had changed insurance companies.” Actually, it is unlikely that Mr. V. changed insurance companies. An HR executive at his employer had changed insurance companies, and Mr. V. was swept along in that change will zero input into the employer’s choice.
- “Apparently a request for 90 pills was flummoxing the system.” Actually, the system was destined to be flummoxed because it was not specialized in dealing with Mr. V’.s complex condition. Even under Obamacare, with its exchanges, health insurers primarily target group markets. The “tip” of the organization — its sales and marketing functions — specialize in targeting groups by size and insurance status (small group versus large group, self-insured versus fully insured) not targeting individuals by health status. So, the “tail” of the organization — the medical director — has to deal with more health issues than can be efficiently addressed under one scope of management.
In a system where individuals could choose their own insurance plan, people would buy policies that protected them from acute costs of catastrophic illness or accident, as well as from changes in their health status. Mr. V. would find a policy that specialized in patients with complex cardiovascular problems, and the friction between patient, physician, and insurer would be much less than it is today.