So know I hear that Medicaid preauthorization is required to administer vitamins in an outpatient setting. One of the greatest things about hospitalist medicine is I can give just about any medication I think is clinically justified to my patients in the hospital. I don’t have any doctor, Dr Nurse, or other third party insurance bureaucrat telling me I have to get preauthorization before my patient can receive care. I have at my disposal a 24 hour all you can eat pharmacy. Sometimes they don’t know what I’m ordering, and my Green Goddess doesn’t get filled. But generally speaking, I get what I ask for.
That’s not the way it works in the frustrating outpatient world of clinical medicine. At every turn third parties are obstructing the care of patients in the name of cost control disguised as quality. Happy’s own insurance recently succumbed to the radiology management movement for high dollar radiology procedures. When I asked my insurance company contact at Blue Cross to provide me evidence based information on how much money they expected to save, they had no data. In fact they weren’t even sure any money would be saved.
When I asked them to show me evidence that such programs improved the quality of patient care, they again had no data to support such a program. In their push to pay for what they call quality care, their policies themselves lack evidence for outcomes. The intent of such programs are to obstruct and frustrate doctors into submission and avoidance of care.
It’s about cost, not quality. One major advantage of an appropriately financed bundled payment model is the removal of such preauthorizations from the clinical equation of patient care. Doctors, with a personal incentive to provide the right care, not the most expensive or the cheapest care are on the hook for complications related to poor medical decision making. That’s the beauty of finance models that align all the forces.
The last piece of such a finance equation is to place a financial responsibility for lifestyle modification onto the shoulders of patients to bear a portion of the cost related to the lifestyle decisions they chose to make or not make. If you can align physician decision-making with patient lifestyle compliance and provide financial incentives to all, I believe the delivery of health care would naturally lead down the most cost effective and efficient pathway possible.
That is certainly not the case with the current Medicaid preauthorization obstructionism occuring. One such example in my clinical practice? Just the other day a discharge prescription for 1000 mcg of IM B12 qday x 7 days then q week x 3 weeks then q monthly was ordered. And the outpatient pharmacy denied the prescription until Medicaid preauthorization was received.
Why did Medicaid deny this medically necessary and standard of care administration for a patient with B12 deficiency? Was it because B12 is a terribly expensive and highly unorthodox medication in need of close regulatory compliance? Nope. Not at all.
You see under Medicaid preauthorization requirements for B12 injection and administration, only 3 ml of B12 can be prescribed in any 30 day period. Yes folks. In the wisdom of cost control your government has decided that only 3 doses of B12 can be administered in any 30 day period without Medicaid preauthroization. Each dose is one ml. Medicaid rules state only three doses are allowed in a month without Medicaid preauthorization.
And guess who gets to do that? It takes Happy’s nurse coordinator over a half hour of uncompensated time to navigate a series of 800 numbers, fax machines, voice mail systems and faceless figures trying to coordinate an effort between a government nurse at a desk job and the pharmacy tech at Walmart.
Who pays for all this uncompensated outpatient care? We all do. With inefficiency comes a greater cost of doing business. And you pay for it with your premiums. This is what medicine has become. A series of preauthorizations required by rigid rules and inflexibility. The solution? Put the power back into the doctor patient relationship. If you are going to pay for health care with other peoples money, stop treating every interaction as a billable encounter and treat care over periods of times. That’s how you bring efficiency back into health care. That’s how you save money. Medicaid preauthorization only makes doctors stop accepting Medicaid.
But, I suppose that’s one way to save money. Ultimately, the patients are the losers.
*This blog post was originally published at The Happy Hospitalist Blog*