Medicaid/Medicare, this is not how it is supposed to be

I’ve been pushed towards my boiling point. Colleagues saw that I could raise my voice. Luckily I did not have one of my famous temper flares.

What has gotten me worked up?

Medicaid!

I saw a consult in the hospital recently. A 50 something year old poorly controlled insulin dependent diabetic with dialysis dependent kidney failure, a serious penicillin allergy, and a below the knee amputation. The patient came in with diabetic ketoacidosis (very bad) and sepsis (also very bad) which we attributed to an ulcer on the remaining foot. Foul smelling and nasty is an understatement. The patient went for debridement and cultures came back with all kinds of nasty microbes but predominantly  vancomycin resistant enterococcus (VRE) (very very bad). I recommended linezolid, a very expensive antibiotic ($50-70 per tablet) that was the only effective choice as well as a couple other antibiotics to cover the other nasty bugs.

The patient was discharged with a prescription for linezolid written by the hospitalist. So why did the patient’s dialysis center call me about a week later to tell me that the patient is not taking linezolid because the insurance company wouldn’t pay for it? Why, upon calling the patient’s pharmacy was I told that Medicaid customers required prior authorization for linezolid? Why didn’t anyone tell me this before? I understand now that the hospitalist doesn’t fill out prior authorization forms and I understand that primary care physicians (PCP) are too overburdened to be filling out prior authorization forms for medications started by other physicians.  But I would have liked to be notified before the patient went over a week without the antibiotic. Apparently the pharmacy had been waiting on the PCP to fill and return the form all this time.

But back to Medicaid and their prior authorization. Prior authorization (PA) basically means that a physician needs to get permission from a patient’s health insurance company (in this case Medicaid) before they can treat that patient with a particular medicine.

So I called Medicaid because I don’t have a secretary or office manager to do such things for me. So instead of seeing patients, here I was on the phone begging.

Me: Hello Medicaid, this is Dr. A. I’m calling about patient X’s linezolid prescription.
Medicaid: Hello, which doctor’s office are you calling from?
Me: I AM the doctor. Dr. A. (the mercury on my internal thermometer has begun to rise)
Medicaid: Ok, so you are calling about the linezolid? What is your NPI number? (NPI = national provider identifier)
Me: blah blah blah
Medicaid: Ok, I’m going to run this through the system and then …
Me interrupting: Why? It’s MY personal NPI not the group’s… (mercury still rising)
Medicaid: Oh ok, this is for linezolid right? 600 mg twice a day?
Me: Yes, just as it’s written on the prescription. A six-week course.
Medicaid: We don’t do six-week courses. We can only approve 30 pills.
Me dumbfounded: But that makes no sense, it’s for osteomyelitis…
Medicaid ignoring me: Well what are you treating? MRSA?
Me my voice becoming more high-pitched and incredulous sounding: V. R. E!!!
Medicaid: Do you have a culture?
Me still incredulous: YES! (Thinking, like duh, how else would I know that I’m treating a VRE)
Medicaid: Ok, did an infectious diseases physician see the patient?
Me: I AM THE INFECTIOUS DISEASE PHYSICIAN (Seriously, and if I weren’t and if the patient didn’t see one, were they going to deny the medication?! Seriously?! Seriously?!)
Medicaid: Ok, so twice daily dosing of linezolid, 30 tablets, that will be 2 weeks duration. This is your approval number BLAH BLAH BLAH.
Me: So what is the patient supposed to do for the rest of the 6 week course?!!!! Should I give a refill x 2?
Medicaid, after a pause: We don’t do refills. You can call back if you want more than 2 weeks. Just give the same details again, but you can’t call until she’s had at least 75% of the current script…
Me thinking this must be a joke, shaking my head: Alright, goodbye!

I called the patient’s pharmacy back. More elevator music. Gave the PA number. Told them to expect to hear from me again in two weeks.

Thought that was done with. Began to wonder if we really need more bureaucracy in the delivery of health-care in America with all the talks about the Affordable Care Act (Obamacare).

Fast forward to this afternoon. I receive a call from the patient’s visiting nurse who helps to administer the intravenous medications and performs wound care. Dr. A I wanted to let you that the patient has not been getting her oral antibiotics.

I think that my blood was done boiling and was way curdled since I calmly let the nurse know that I had taken care of it and the patient should be able to go to the pharmacy and pick up the linezolid.

But why couldn’t the patient pick up the other oral antibiotic? It’s generic, probably 50 cents per tablet. So I told the visiting nurse to hold on and called the pharmacist. Yes, because I have nothing better to do than be on the phone all day long. If only I was a lawyer, I would set the timer each time I placed a call on behalf of a patient and then send them the bill for reimbursement of my time. But that’s a doctors fantasy; we can only dream.

Pharmacy told me that the patient already picked up the other medication. I cal back the visiting nurse. “Hmmm”, she says, “that’s interesting”, then she sighs. “Dr. A, you have to know that this patient is difficult. The home is in shambles. The family doesn’t seem to care. The bandages are always dirty. The patient unkempt. I asked them if they had filled their medications the first day I went to the home. They said yes. I asked yesterday for them to show me the pills. That’s when they told me insurance wouldn’t fill them. Doctor, the patient is non-compliant. They don’t always go to dialysis. Doctor, when I took the dressing down yesterday, it was just foul, foul odor. I wanted the patient to go to the hospital, but they refused. They say they don’t have transportation. When they went to dialysis yesterday, we were able to get a surgeon to go there to take a look at the wound. They don’t even have a land-line, doctor. They use cellphones but they’ve used up all their minutes so now they are not answering their calls. I will go there again today and make sure the patient is taking their meds. But doctor, the patient is non-compliant …”

I sigh. The combination of unnecessary bureaucracy and people’s lack of interest in their own health and/or their inability to advocate for themselves is just too much for me to handle today.

Earlier this week, it was another patient scenario that had my head shaking. This time the nemesis was ICD codes.

Thank goodness it’s Friday and I’m off for the weekend!