Del Meyer, MD, Pulmonary Medicine

Hippocrates' Modern Colleagues

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Pharmacy Practices are Hazardous and Costly

by Del Meyer

 

Almost all physicians are getting into the habit of giving adequate prescription refills and eliminating the need for patients to call in for prescription refills or having special lines reserved for patients to call in. They are learning that phone refills are not only hazardous, but poor business practice.

This is accomplished by the physician at the time of appointment, who, with all the information at hand, determines a safe period for the patient to take the medicine without further evaluation. Then the number of refills to that evaluation is given when another prescription will be written. Thus, if the patient should be evaluated in six months, then the total refills would equal six and the patient knows to make an appointment when the sixth refill is filled. The same for a 12-month refill. 

At a recent meeting of an insurance company, a pharmacy service company was expounding on their ability to automatically send faxes to the doctor when the last prescription is picked up, which will always be one month before the required appointment. They even bragged that they could send out daily faxes until the doctor responded. We recommend that a doctor should not respond to these requests in view of the hazards involved and the costs of this practice.

They are hazardous because pharmacists assume that all that is required is a simple yes or no answer after which they can proceed with refilling a prescription that hasn't been authorized by the doctor with the patient and his/her chart in front of him/her. This will assure the pharmacist of return business without the possibility of patients having a new prescription in their hand, which could be taken to another pharmacist. But the physician had made a determination that the patient needed further evaluation when the refills are completed and thus appropriate health care is subverted. We recommend that a doctor should not respond to these requests in view of the hazards involved. Faxes can now be programmed to block such calls from repeat offenders.

Phone refills are an excessive cost to a medical practice. To refill a prescription, doctors know the risks involved if the chart is not pulled and reviewed and a new determination is made. Phone refills are basically an office visit without an exam. Therefore, the actual cost of this phone request is about half that of an office call. However, there is no payment for this half-office evaluation. If a doctor sees three patients an hour, and three refills come in during the same hour, the professional income is cut in half.

Attorneys have long known that phone calls are expensive. But they have the mechanism to charge for their time on the phone to their clients. Most law firms have a minimum time per phone call, such as one-sixth or one-fourth hour. Thus, if you have a junior attorney in a firm charging $300 an hour, the phone call is automatically billed at $75 for one to 15 minutes of time, and $150 for 16 to 30 minutes of time. The cost of a senior attorney at $400 an hour would be $100 for each quarter hour or less. Attorneys cannot take the risk of possibly giving out legal recommendations without all the facts in front of them.

The same thing applies to physicians who should not take the risk of giving out information, recommendations or refills without all the facts in front of them. Physicians need to establish a fee structure to take care of this practice much as attorneys do. If they don't, liability increases and malpractice premiums will rise to cover this liability. Meanwhile, physicians must ignore all pharmacy requests for new prescriptions or refills beyond those initially authorized.

 

 

Changing Doctors May Increase Cost and Decrease Quality

by Del Meyer

 

Marjorie had pleural and parenchymal tuberculosis as an adolescent. Hence she had parenchymal (Lung) nodules in the apex of her lung and thickened pleura in the lung base on one side. She had been appropriately treated with antituberculous drugs. She then followed the prescribed regimen of follow up x-rays every three months for two years, every six months for three years and then yearly.  If the new x-ray, when compared to the old x-ray, was essentially identical, one could safely say there was no recurrent activity.

She went to the emergency room for a minor trauma and cut to her hand on Friday evening. This was treated and a chest x-ray was obtained for reasons unclear. No medical indication was recorded on the requisition. The x-ray was very abnormal. Since her previous x-rays were done elsewhere, there were none to compare. Hence, the radiologist appropriately listed all the findings, suggesting multiple etiologies, and suggested studies to rule out tuberculosis, cancer, or multinodular disease. The hospitalist on duty in the evening admitted the patient and ordered a sputum culture for TB, isolated the patient against her wishes and demands, and ordered a CT of her chest. The hospitalist on duty the next day, proceeded with the same direction of testing, and started antituberculous treatment. The family became very anxious when their wife and mother was thought to have reactivated her tuberculosis. The patient subsequently stated that neither hospitalist doctor that admitted her or the one that saw her the next two days on the weekend asked her about her known tuberculosis, the treatment in a sanatorium, drugs for two years and numerous follow up x-rays.

On Monday, she saw a third hospitalist who sat down and spoke with her and obtained the first real medical history. He made a phone call to the pulmonologist who faxed him Marjorie's medical history and x-ray reports. The decision was made in a matter of minutes that the only problem was a minor laceration that was sutured in the Emergency Room and was clean and healing well. There had been no medical reason for the hospitalization and no reason to suspect tuberculosis reactivation. He promptly discharged her with directions to have her sutures removed in one week.

This is not an isolated case. It is a frequent occurrence in practice because the patient's personal physician is excluded from taking care of her in the hospital, thus interrupting the efficient continuity of care. Although many studies and reports continue to show the efficiency of having a fulltime hospital physician who is in the hospital continuously, this is frequently not the case. It may be the case in an acute care situation where the treatment changes from hour to hour, but in a large percentage of cases, the patient only needs physician supervision once or possibly twice daily. This has been the usual standard of care for many decades and still is.

There needs to be further study on the new so-called specialty of "hospitalist" - not primarily directed to hospital efficiency, but to cost effective efficiency. This is a very difficult study to do since many of the hospital charts no longer reference the prehospital care. Hence, the study would show cost-effective care when looking at the entire spectrum of care; it may not be cost effective to the patient or improve the quality of care.

 

Emergencies May Represent Desperation

by Del Meyer

 

One morning when I was in the US Air Force working in the internal medicine clinic, a call came in about 11 AM from the operating room asking me to come to the OR in all haste to manage a cardiac arrest. The chest had been opened and the surgeon was vigorously compressing the heart. I managed the monitoring equipment and ordered the intravenous infusions to restore cardiac activity. The heart was responding and the surgeon was preparing to close the chest. I sent a message to the clinic to reschedule all my routine appointments. Rather than go to the mess hall for a lunch break, I would see any emergencies at that time. When I arrived about 12:30, who was there for me to see rather than have lunch?

I found the cancer, heart, diabetic, and emphysema patients had all been rescheduled for later in the week. The patients with backache for 20 years, neck pains for 15 years, abdominal pains for 10 years, and arthritis for decades were all waiting for me to take care of the crises in their lives. Their charts were all two to four inches thick. They all had the necessary tests done several times over and nothing that was reversible could be found. They were very disappointed when I reviewed the extensive charts revealing that all the necessary tests had been done repeatedly. Yet they all had a crisis in their lives they thought I could take care of in a few minutes on that day on an emergency basis and restore their health. However, they all had permanent impairment and were unable to accept the fact that numerous physicians had advised them that their back, neck, and arthritis would never function as new or that the abdominal pain was chronic but could be controlled with the medications they were already getting yet refused to take because they didn't want treatment, they wanted cure.

What went wrong? Practicing medicine is a very difficult profession. It's hard to clinically ascertain where each patient is at in his or her thinking during the appointed allotted time. If the physician doesn't connect with the patient, the patient will not accept or even hear what is said. Some of us are more successful with some types of patients and others of us are more successful with other types of patients. When the trust connection cannot be made, the patient should take some responsibility to be frank with the doctor and perhaps make a change in physicians.

In the military, it may be hard to choose a personal physician. But there comes a point, after numerous tests have been done several times, that one must disengage from frequent medical calls. This may also be difficult to do because the visits are free and can go on for 20 or more years during a military career. Many of these charts represent a medical cost equal to a luxury car or to a home. It is indeed unfortunate that in health care one can utilize this degree of resources without significant responsibility. One presidential candidate wants to extend the amount of irresponsibility while the other candidate wants to reign in some of these costs. Future financial consequences don't matter in the heat of the campaign. The fact that all entitlements are facing an endpoint doesn't register with all Americans. The fact that government medicine causes multi-year waiting in many countries doesn't register either. They all think there are hidden government resources that still can be tapped. That's only because of dishonest politicians who don't speak truthfully to their constituents. We can't entirely blame a president with 25 percent approval rating when all spending bills originate in Congress with a 14 percent approval rating. The least we can do is to keep Congress, which 75 to 86 percent of us don't trust, from writing more medical laws and regulations. We must vote these incompetent folks out of office.

Don't let Congress determine our health care needs. They don't understand them.

 

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