Healthcare Spending Limits

May 16, 2016
Melissa Young, MD

Do you think the effort to decrease healthcare spending is spinning out of control? Is the cost of red tape exceeding potential healthcare savings?

I understand the need to attempt to limit healthcare spending. I understand that drugs are expensive and that it makes sense to use a less expensive drug if it is equally as effective and safe. I understand that the latest and greatest drug isn't always the most appropriate choice for a particular patient. I don't understand why, once a drug has been deemed to be safe and appropriate for a patient, we need to prove it again every 6-12 months.

For example, a patient on testosterone replacement. Before starting initial therapy, there are certain questions that are asked before drug X is approved. Is the patient male? Is he over age 18? Is this for hypogonadism? Are there two pretreatment lab values below the normal range? Is there a contraindication?  Depending on the plan, there may be a couple (or a dozen) additional questions. So let's say that drug X gets approved for 6 months. In 6 months, we are asked the same darn questions all over again. Well, he would still be male, over 18, with hypogonadism and his pretreatment lab values would be the same! The only potentially different answer would be if there is now a contraindication. So why not just ask that?

Furthermore, if someone has been on therapy and has been stable for the last 10 years, but changes physicians, if that new doctor doesn't have access to the old records, the drug may be denied. I just had an insurance company tell me that the patient would just have to stop therapy for a while and then get labs done if I can't produce his pretreatment labs.

And don't think it's just testosterone. A patient of a colleague of mine was told that her insulin pump supplies would no longer be covered because her diabetes was under good control and the supplies are only covered for people with poor glycemic control. But, she had poor control, now it's good because she is on the pump. And speaking of pumps, how often do we have to prove to Medicare that a patient isn't making insulin? Once a C-peptide is low, why do we have to repeat it? Will a patient suddenly start making insulin again?

Like I said, I understand the need to limit healthcare spending, but we also need to eliminate redundancy and paper-pushing.

 

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