Outrage #1: Wasting time of skilled caregivers.
Everyday skilled
nurses and physicians’ assistants waste hours of time on the telephone either
getting approval for medications that we prescribe for our patients or trying
to fight a rejection for a medication we requested.
Outrage #2: Choosing a medication for cost, not
effectiveness. A
child cannot breathe because the acid and other nasty stomach contents come up
from the stomach and inflame the airways without the right treatment. Although
many of them might respond to one “preferred” drug, not all of them do. And,
guess what? There is another “non-preferred” drug to which more of them will
respond, but it is not allowed as a first line treatment, even in this critical
airway situation. When there is an airway problem and the infant is choking,
coughing, turning blue and not sleeping, or the airway is becoming
progressively narrower, wouldn’t you want your child to have the medication
that works more often? I know I would. The insurance companies call their
approach “best practices” because most, but not more, might respond.
Outrage #3: Pretending we are giving care when
we are not. So the
one “preferred” (i.e. less expensive) medication also tastes really nasty. Many
kids won’t take it at all no matter what flavor is used. So then families are
told to mix it with their formula or juice or some other food and this dilutes
its effects because it won’t work in that preparation.
Outrage #4: Pretending that patient diversity
doesn’t exist. Different
people respond to medication differently (? pharmaco-genetics). You know that’s
true just from the way some of us fall asleep after one dose of Benadryl and
others of us don’t get knocked out even with a whopping dose of morphine. We
are in a real quandary when we have to fight (sometimes for weeks or months) to
try another medication because the one we are allowed (first tier) doesn’t
work. And then on the second or third tier, the family cannot afford it,
doesn’t get the medication, and the child might go untreated. We have wasted
money, time and have put the child in harm’s way.
Friends, I
am not making this up. And the problem is going to get worse. Why? Because
there are some with influence who really believe (incorrectly) that there are
“experts” who know the right thing to do for an individual patient, whom they
have never met. Well, they don’t. Each patient has a unique set of variables
that requires a lot of thought before prescribing occurs. I have just named a
few.
This
misguided approach to patient care is much more eloquently discussed by Pamela
Hartzband, MD and Jerome Groopman, MD in an editorial in the Wall Street
Journal. I was so pleased to see that these two brilliant Harvard minds (wife
and husband) have continued to chip away at the myth that there are such things
as “best practices” or that “expert opinion” will result in the best care for
all.
In my
almost 10 year tenure as director of the Center for Pediatric Quality at the
Children’s Hospital, I firmly resisted even using the term “best practices,”
because I truly believed that there were only “better practices.” What we think
is best today would and should be replaced by what is better tomorrow. That is
what makes medicine challenging and what creates the forward movement of innovation.
We have benefited from the explosion of treatment options for people who didn’t
get treated 30 years ago because they were developmentally disabled or too old
to undergo an operation or for whom the technology did not exist.
Yes, I am
angry about this. Very angry and very frustrated. I am tired of being told what
medications to use, what tests I can order and even what surgeries to perform.
I am “appealing” to one insurance company to be paid for an operation they said
was not proven effective in children. Were they faced with the anatomy that I
encountered and knew was the cause of the problem and required a different
operation than planned? Another has denied payment for an assistant surgeon
which I needed because we performed a difficult airway case!
Should I
have risked the child’s airway without another pair of skilled eyes and hands?
And recently another applied criteria for tonsillectomy (which were outdated
and wrong) and said the kid didn’t need it because my charting was inadequate.
In every instance I know my judgment was correct, but their “expert panel” who
might reads an article but has not been with this patient, comes up with a
sweeping policy and applies it to all of the patients. It’s a joke that’s not
funny.
So who
needs doctors? Increasingly insurance companies and the government tell us what
is best for our patients? That is what is happening. It is making me really
angry. What about you?
See original publication by Linda Brodsky, MD (Physician), December 7, 2012, on medpageTODAY'S KevinMD.com Social media's leading physician voice.
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