So here's how low we have fallen: The Phantom gets a sad phone call from a patient who says the office of the doctor for whom the Phantom was covering faxed a prescription into a 24 hour CVS, but whoever filled out the RX forgot to write in the diagnosis code (250.02) which Medicare requires, so the pharmacist refused to fill the prescription. The pharmacist did offer to sell the patient the insulin for $160, which is about a week's pay for this particular patient. But even though the patient had all his Medicare papers and card in a row, the pharmacist refused to run it through Medicare because the doctor's office forgot to write the diagnostic code for diabetes--the only disease insulin is used to treat.
The patient is completely out of insulin and of course it's Friday night at 9 PM.
Our usual rule is if you are dumb enough to run out of insulin on a weekend, then you have to pay cash for your insulin. Your lack of planning is not our emergency. That is your punishment for failing to plan ahead. Patient has to pay out of pocket once and he never lets that insulin Rx lapse again. As the doctor, if you don't get tough about insulin, your life becomes unmanagable, because you get an unending torrent of phone calls from patients every Friday night, Saturday and Sunday. You get people who plan to fill their prescriptions over the weekend, because it's easier calling the on call doctor than it is to deal with the office staff during the week. You have to train your diabetics to behave, when it comes to insulin.
But, in this case, the patient had done the right thing; it was someone in the doctor's office who fouled up, and now it was the pharmacist who refused to simply write the DX=250.02 on the prescription even when the doctor told him to, because the "Medicare rule" is the doctor has to write this on the prescription. (Of course, every pharmacy seems to know something different about Medicare rules.) The pharmacist said he could not take a phone order. The doctor had to write it himself and fax the RX into the pharmacy. If the doctor did not have a home fax, well then drive to the office. But, of course the office building is locked, so go find an all night Kinkos. The pharmacist was willing to deny the patient his insulin to follow the letter of the law.
Now, you could argue, the pharmacy is simply enforcing on the doctor the same discipline the doctor enforces on his patient: Fill out that Rx properly or you wind up inconvenienced and bothered. But, the doctor may not do that, may not be able to do that, may simply send the patient to the ER (for which Medicare would get an $800 bill, at minimum) or the patient may give up, go without insulin and wind up in the hospital for a few days at a cost of thousands to the system, all because of insistence on inconsequential details.
And we wonder why Medicare costs are high.
The story gets even better: The patient arrives at the pharmacy and the insulin pen is ready but there was no prescription for the needles. You need to fix a needle to the pen to be able to inject the insulin. Oh, you wanted tires with your car? Actually, the prescription said, "Novolog pen + needles." But the pharmacist wouldn't fill it because "Medicare rules" say the needles have to be a separate prescription. More calls, more faxes.
But the best part is, it turns our Medicare does not have a contract with Novo, which makes the Novopen, only with Lilly which makes the Humalog pen. There is not a gnat's eyelash difference between the two, but a new prescription has to be written, faxed.
A typical endocrine office faxes a hundred insulin prescriptions a day. What are the chances some box will not be filled in? If only 10% are missing a birth date or a DX code, or misspells the patient's name, that's 10 phone calls every night, often to a covering physician who doesn't know the patient, his birth date or the spelling of the name.
In most systems, you say, okay, let's be tough on the rules which really matter to the functioning of the system, to the safety, clarity or integrity of the system, but for things which are really just book keeping, which could be tidied up in the day light hours, you punt. That's called efficiency and rationaltiy.
Efficiency and rationality do not characterize the world in which today's doctor functions.
Large parts of the medical system are no longer "professional." The clerk who knows only whether or not the box is checked has no clue why the box needs to be checked, who does not care why its important the prescription is filled or what the ultimate goal of the system is; he is not a "professional." He is a functionary. He works in his part of the assembly line, on the fender bolts. He doesn't care whether or not the care has an engine, whether or not it can run. He just puts in his three bolts, draws his paycheck and goes home. It's the job of the designers and engineers, the "professionals," to set up the assembly line so a working car emerges on the other end. It's not up to the assembly line worker to think about whether or not that bolt has to be sunk in place.
But, of course, the pharmacists wear white coats and call themselves "professionals." They have schools and accrediting exams, but they do not behave in any way more "professionally" than the guy on the line placing bolts in the fenders. This is because the pharmacy is a for profit business. Almost whenever you get the profit motive mixed into medical care, you have poisoned the well.
This is not limited to pharmacists working for big corporations, in fear for their jobs. Of course, the pharmacist is not judged for his judgment; the pharmacist's job is not care for the patient; the pharmacist's job is making sure the company gets paid and profits increase.
In for profit models of health care systems, whether they run hospitals or physician groups, the same is true. Bean counters rule in a destructive way. Bean counters become drunk with power and self importance.
Of course, it is not only for profit systems which are ruined by the self interest motive: The cop on the beat, who actually does try to "serve and protect" becomes the forgotten man, not to mention the citizen who the cop or the doc is trying to serve. The career men, the Lieutenant Rawls and Deputy Commissioner Burrell care nothing for the people their organizations are said to be serving. They care only about themselves. They are Ayn Rand's heroes.
Maybe big organizations have to function this way--each person on the assembly line just punching in his bolt, not caring about the organism he's helping to create. People have been complaining about the loss of pride in workmanship since the assembly line was created. In medicine, each piece of a physician's job has been broken down into it's components and assembly line workers hired. The blood pressure is checked by a medical assistant. The dermatology tech cuts out the mole which needs to be biopsied. The ultrasound tech does the thyroid ultrasound. The physician's assistant uses the buzz saw to cut through the sternum, while another PA harvests the blood vessels for the leg and a third cuts down to the heart. Only when the blood vessel grafts need to be sewn in does the surgeon enter the room, takes his 20 minutes sewing in the by passes and moves on to the next of the 12 rooms he will visit that day of doing coronary bypass procedures. The "certified diabetes educator" who may be a nurse or a dietician reviews the blood sugars and adjusts the insulin doses. The nurse practitioner listens to the patient's complaint of cough and orders a chest X ray or a CAT scan and writes a prescription for an antibiotic and sends off a blood count and maybe fifteen other lab tests the patient may or may not need.
And, in American medicine at least, all this happens in the name of cost cutting and efficiency. But is it really cheaper to have three physician's assistants in the operating room? Is it really cheaper to have that physician's assistant ordering MRI's and CAT scans and unnecessary lab work?
Somehow, in America, with the addition of all these assembly line workers, costs have continued to rocket upward.
"Medicine is too important to be left in the hands of doctors." An old line.
But if not doctors, who? Do we trust MBA's more?
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