Stupid Fights

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I recently wanted to prescribe a medication called Prevacid for a patient.  It’s a proton pump inhibitor that shuts off acid production in the stomach.  It’s used to treat a wide variety of gastrointestinal complaints, most commonly heartburn, which is the malady I was aiming to treat in my patient.  She was strongly resistant to starting it, however—not so much out of concern about its safety (it’s quite safe), but because, like many people, she simply didn’t like taking medication.  I was sympathetic but also felt that Prevacid had the greatest chance to help her feel better.  A long discussion ensued after which she agreed to try it.

And then her insurance company refused to cover it.  I ended up having to spend two hours over two days making the argument that the treatment was medically indicated.  I hung up the phone after I’d finally gotten them to agree and found myself thinking how stupid it was that I’d had to talk with them at all.  If a physician writes a prescription for a patient, doesn’t that mean, by definition, he or she thinks it’s medically appropriate for their patient to take it?  Why should doctors have to spend any time explaining the appropriateness of their actions in those instances where their actions explain themselves?

In the course of caring for patients from day to day, some obstacles bother me far more than others.  Having to take the time to explain to my patient why I thought Prevacid was a good idea for her and having to listen to and address her concerns about it, for example, didn’t bother me at all.  It’s entirely reasonable and even desirable for patients to question the interventions doctors want to make with them.  It leads to dialogue (or should) that can often result in important changes in the doctor’s plan that benefit the patient.  I welcome the particular challenge of working with patients to increase their compliance with treatments I believe will benefit them.  I like patients to think, to ask questions, to assume ownership of their own health.

I don’t, however, like having to repeat myself to insurance companies.  I understand their desire to contain costs.  But forcing doctors to justify the prescribing of FDA approved medications makes little sense.  It’s not a challenge I welcome at all.  It’s an obstacle I’d rather avoid.

We all know to expect obstacles whenever we take aim at a specific goal.  But what my conversation with the insurance company made me realize is that those obstacles are rarely the ones we want.  We can’t help but anticipate the kinds of fights we have ahead of us when we embark on a plan to accomplish something.  But when those fights aren’t the ones we expect we’re likely more than anything to become annoyed.  This, in my view, represents a serious problem.

When we anticipate an obstacle, we can’t help but mentally cast our minds forward, envisioning how we might handle it.  Often we develop possible avenues of attack, which makes the obstacles seem less daunting.  Surmountable, even.  We may even worry less (preparation, as I wrote in a previous post, prevents poor performance).  But when we come up against an obstacle we didn’t anticipate and become annoyed, we become far more likely to attempt to avoid it than overcome it.  Because of this, we’re more likely to be defeated by unexpected obstacles than expected obstacles, even if the expected obstacles are far more formidable than the unexpected obstacles.  We’re simply more likely to complain about stupid fights than to actually fight them.

The real threat unexpected obstacles pose, then, is to our attitude—and attitude is everything in sustaining one’s resolve to overcome an obstacle, large or small.  Hence, the real risk of failing to achieve a goal doesn’t come from the most implacable obstacles; it comes from the least expected ones.

The solution?  Expect the unexpected.  We can’t, of course, predict the specific nature of unexpected obstacles but we can predict the fact we’ll encounter them.  So when unexpected obstacles arise, as they invariably do, and you find yourself annoyed and thinking of them as stupid (as I did my encounter with the insurance company), force yourself to recognize what your mind is doing so that you can prevent it from having a deleterious effect on your attitude.  In this way you can prevent unexpected obstacles—even small ones—from stripping you of your most effective obstacle-buster:  resolve.  Don’t be discouraged by having to face stupid obstacles.  Don’t let them wear you down.  Ignore your own indignation and calmly attack—even those obstacles you don’t think you should have to—like a lion trapping an ant.  Remember, it’s not the strongest opponent who’s most likely to defeat you, because that one you can prepare for.  It’s the one you underestimated, because that one you can’t.

Next WeekBoredom

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  • Ooo, love the last sentence.

  • “If a physician writes a prescription for a patient, doesn’t that mean, by definition, he or she thinks it’s medically appropriate for their patient to take it?”

    Pharmacists perspective: It’s not about you thinking it’s appropriate, it’s about step therapy. You even mentioned it, it’s about containing costs. I read a pharmacoeconomics statistic that said if we utilized optimal generics first line and complied with cost-effective step therapy, we’d save 80% of what we currently spend as a nation on Rx drugs. That’s outrageous.

    Prevacid should rarely if ever be written for before omeprazole is tried and failed first, as all PPIs are equipotent if used in equivalent dosages, and omeprazole is by far the cheapest PPI. Prevacid’s generic costs significantly more than omeprazole so it’s understandable the insurance company wants to know why they’re spending more money on a first line drug than they really should be.

    It’s even more dramatic when it’s something like Lexapro tried first line, which costs 10-20x more than the generic SSRIs. The same thing with Nexium. There’s a good reason those two drugs are prior authorization on a lot of insurance plans…they’re huge money wasters if substantially cheaper drugs would work just as well.

    I spend a large part of my day helping optimize therapy for patients who cannot afford their meds or who have insurance companies putting up a fight, so your story here hits home.

    Wes: I didn’t mention that I’d already tried omeprazole with my patient because the use of generics vs. newer brand-name medications wasn’t the thrust of the post. But you raise a valid point.


  • Alex,

    Another interesting post (and comments).

    My first reaction was to agree fully with your assessment of the stupidity, and I watched myself re-activate a familiar response pattern in my mind: “Oh, what bureaucrats and bean-counters.”

    One certainly wants to believe that those in the approval chain (or reimbursement chain) will understand and appreciate your expertise, knowledge, and sense of right and wrong. Of course, that is only true in a small team or company, where everyone knows each other, and can factor in their own perspectives of competence and motivation.

    But you are talking about that large machine called bureaucracy. And I do have what I’ll call a “hang up” where I have no desire to feel like only one small cog in that vast mechanism. I guess, for me, that comes down to ego. And to my belief that somehow I would do it differently if I were sitting on high.

    So your suggestion “Don’t be discouraged by having to face stupid obstacles. Don’t let them wear you down.” is something I really need to work on. Because sometimes I wonder if the battles (or more often, little incursions) are worth being fought. Indeed, I will likely spend my preparatory time seeing if there is another approach to take which might avoid that bureaucracy altogether.

    And the comment from the pharmacist was particularly helpful, for it juxtaposed my instinctual agreement that “they” are just “stupid,” with a recognition that there might well be a worthwhile reason (containing costs and assessing cost-effectiveness) in their decision making process.

    Something more to think about on a Monday morning. Thanks Alex.

  • […] This post was mentioned on Twitter by Gary Wan BH, Alex Lickerman. Alex Lickerman said: So often the fights we need to fight aren't the ones we want to fight: […]

  • Alex, thank you for sharing what has become a common frustration among physicians, and something, I’m afraid, that is driving many to early retirement. Wes gives a good explanation of the need to control costs, and I think by now most physicians are fully aware of the ways to do so, including trying generics first, etc. The real problem is that there are so many payers (insurance plans) with so many different formularies and sets of rules, that we usually don’t know what it is we must do first, in order to get the prior authorizations. And pharmacists are often no more enlightened than we are about the rules. January is a nightmare: people change insurance, insurance companies change mail-order pharmacies, formularies change and the rules change. As a result, we end up making changes to stable medication regimens in patients who have been doing well, just to appease the insurance companies. And these companies are playing to the very thing that is Alex’s point: we would rather avoid than overcome an obstacle. The payers know this, and put up ridiculous obstacles with the certainty that in most cases we will take the path of least resistance and go the cheaper route, for better or worse.

  • I appreciate this post! Like many (most?) of us, I can get really p***ed off at unexpected obstacles (and there are so many of them!). My gut reaction is resistance: don’t bother me! Don’t get in my way! Just let me do what I need to do! And of course, that doesn’t remove the obstacle or help me deal with it. It just messes with my blood pressure. I’m going to print out your last paragraph and roll the idea around in my mind. It just might help me make the shift in thinking that I need.

  • I agree with the point about doctors having to argue with Insurance companies over the treatments for their patients. My husband is diabetic and our plan just decided to make him switch his meter (no biggie); then they decided he only needed to check his blood once a day not twice. So they won’t cover the extra strips & lancets unless our doctor calls & explains why he needs them. Since his parents both died from diabetic complications which has been reported to the insurance company prior I think it’s crazy that she has to waste her time to call & get the approval! They won’t cover my RA meds because they say I can do ok on a cheaper one which was tried and failed; they are not my doctor!! We pay our premiums so we deserve proper care w/o hassles.

  • It probably won’t work in the human med world but in the veterinary world it used to be the philosophy that if you needed to do it (dental work for example) but couldn’t stand doing it, you just kept raising the price until you enjoyed doing it. Solved lots of frustration and you only had to deal with the patient as there is no real insurance in the normal animal world. So for you, just raise the consultation fees for the patient and talking to insurance companies until you like talking to insurance companies. There will come a point you will be glad to call them. That will make you “happy in this world.”

  • I’m not living in the USA, so it might not happen there. But in my country there’s a profession, roughly translated as “visitor of doctors”: someone hired by pharmaceutical companies, visiting MDs, arguing that when they can, they should prescribe a certain pill—and arguments often, if not always, include money (eg. a very expensive holiday, gratis, for you and your family, in case you happen to have prescribed it most times—all under the name of a “conference,” of course). I know someone who used to work for such a company, and heard it from doctors, too; and even laws were made to control that.

    Here, if someone would second-guess a doctor, this would be the first thing coming to my mind—here if someone wouldn’t prescribe the most obvious choice, it’s not always because it’s better for the patient.

    My point is, that stupid fights very often turn out to be quite reasonable from a previously unknown point of view. I still get mad to stupid obstacles, but behind every stupid rule, every stupid fight there’s a soul, there’s someone trying to do what’s best. I may not agree with his/her views; but it’s always there, and more often that not, if I knew more, I understood them better. This belief usually helps me to stay more patient.

  • Alex,
    This entry resonates all too clearly with me. I too am a primary care doctor and struggle daily with the inanities of our health care system. It really is no wonder that fewer people are choosing primary care as a career option. Your example is but one case in an ocean of cases that illustrate the shifting of the burden of cost containment onto the primary physician. The fact that most readers may not realize is that doctors, unlike lawyers, cannot bill for time spent on the phone or filling out tedious “prior authorization” forms for medications or imaging procedures. I spend between 2 and 3 hours per day doing just that and have often considered quitting primary care because of it. What really gets me is that I have undergone 10 years of training to do this job, and I am treated like an idiot by someone with no medical training at all. I often feel that the forms and telephone systems are purposely made more complex than needed simply to break the will of the PCP to even lift the pen or dial the numbers. The ultimate goal is cost containment but the means to that end involve a fast track to burn-out for the physician. So, I’ve considered quitting. But, then, what stops me is that I realize that I hold a privileged and respected place in the lives of my patients and colleagues. I am paid well enough and truly needed by my community. I am better off than most of those that I serve. I realize that my patients too are trapped in this complex and frustrating web of red tape and that they depend on me to get them through it. So, while these “stupid fights” are the things that I loathe the most about primary care, I grit my teeth and fight the good fight, because that is my duty.

    John: You and I think the same exact way.


  • Anger is born out of broken expectations. Change your expectations and you change the way you feel.