State of health care: Times are changing

Issue: May 2012

ByRichard O. Dolinar, MD

Once upon a time, not so long ago, I used to be a doctor.

Now, I am told that I am a “health care provider.” Last week, a caller from a pharmacy (Pharmacist? Tech?) addressed me as Mr. Dolinar. Soon, if this keeps up, I will probably be called, “Hey, you over there, with the stethoscope around your neck …”

I used to treat patients.

Now, I care for consumers/clients.

I used to look at the patient and observe them closely for any clues or tell-tale nonverbal communications that would reveal, in a very subtle way, what was truly distressing them.

Dolinar_Richard
Richard Dolinar

Now, I look at the computer and, depending on the room, my back might be to the patient. It is the computer screen that I now observe closely for any prompts for “meaningful use” items that I need to be sure are in my notes.

I used to order medications, therapies and hospitalizations for my patients.

Now, I request them, beg for them, cajole for them and often await prior approval authorizations from people at 1-800 telephone numbers. Some of them are doctors (although this is usually the exception), some are nurses, others are high school graduates and some, for all I know, might even be high school dropouts. Most are usually sitting in front of a computer screen as they attempt to determine the “appropriate care” for my patient, whom they haven’t ever seen, talked to or examined. As they attempt to dictate to me what drugs will be used on my patients, the exchanges can be telling. Today, for example, my office staff was told that I needed to use a lower dose of exenatide extended-release for injectable suspension (Bydureon, Amylin) or it would not be covered. How am I to use a lower dose of a medication that only comes in one dose?

I used to go to the hospital to treat my patients and consult on other doctors’ patients.

Now, the hospitalist admits and treats. Many times, my own patients are admitted and treated without even notifying me. Not notifying me, that is, until after the discharge. An actual call from one of my patients went something like this: “Dr. Dolinar, I just got out of the hospital an hour ago and ‘they’ (whoever ‘they’ are) told me to call you to find out how much insulin I should take. I was admitted a couple of weeks ago for emergency surgery and developed a severe infection. I almost died. So, how much insulin should I take?” Rarely, do I get called for consults anymore. The hospitalists are quite capable of writing orders based on disease guidelines provided by the specialty societies.

I used to go to the nurses’ station, and there actually was a time when nurses would offer their chair to the doctor. That was back in the days of the 8-hour nursing shift.

Now, many of those chairs are used by ex-nurses employed by third-party payers checking on the patient’s status. They sit, taking up critical space at nurse stations, which are often very cramped and crowded to begin with. They have “important” sounding names such as “insurance liaison,” etc. I call them “checkers,” and to this day, continue to wonder, “Who checks the checkers?”

I used to treat diabetic patients as their situations indicated, being careful not to use medications in “contraindicated” ways.

Now, I am told that hypoglycemic drugs are “not indicated” combined with each other unless clinical studies have been submitted to and approved by the FDA for such use. And third-party payers will not pay for them because they are not indicated, even if they are effective and not contraindicated. But what about using any hypoglycemic medication with any lipid-lowering medication or any hypertensive medication? Every time we use more than one medication on a patient, aren’t we usually using a combination that has not been evaluated or approved by the FDA and is, therefore, not indicated? Should we therefore not use it? Should we advise our chronic obstructive pulmonary disease patients to stop their inhalers because we want to start a hypoglycemic agent? Should we tell our cardiac patients to stop their cardiac meds because we want to start a statin? Why is it that only the glucose-lowering medications are held to this standard? Why aren’t various combinations of blood pressure pills or lipid agents held to the same?

I used to, and still do, continue to see things change in health care.

Now, however, it is clear to me that some things will never change. I will always be medically and legally responsible for my patient, even though I may not be allowed to use my first choice of medication, hospitalize the patient when I think their condition necessitates or even use my best medical judgment instead of an algorithm.

Will this all end “happily ever after?”

Richard Dolinar, MD, is a senior fellow in health care policy at Heartland Institute in Chicago and a clinical endocrinologist in private practice in Phoenix. He is also an Endocrine Today Editorial Board member.

Disclosure: Dr. Dolinar is a paid speaker for Amylin.