An Apple A Day

You’re familiar with the first part, or a variation of it, but did you know the rest of this Mother Goose nursery rhyme?

An apple a day
Sends the doctor away.

Apple in the morning,
Doctor’s warning.

Roast apple at night
Starves the doctor outright.

Eat an apple going to bed,
Knock the doctor on the head.

Three each day, seven days a week,
Ruddy apple, ruddy cheek.

100-Year-Old Marathoner

Fauja Singh completes Toronto marathon.

According to the Wall Street Journal, on 10/16/11 Fauja Singh completed the Toronto marathon, finishing the 26.2 mile race in over 8 hours. I hope that will inspire my patients to exercise. I’ve started telling my octogenarians to start training for a half marathon. Heck, I’m letting them off easy.

How Primary Care Docs Became Assistant Shoe Salesmen

Nurse practitioners, physician assistants, pharmacists and naturopaths have gained the right to prescribe medications traditionally only done by a physician. But the Medicare Therapeutic Shoe Bill requires that the physician managing the diabetic condition certify the need for footwear and inserts.

So although the podiatrist truly has the expertise in this arena, it falls on the patient’s primary care physician or endocrinologist to do the paperwork. Congress might have been concerned that because podiatrists profit from selling inserts or shoes, that someone else should determine whether it’s really needed. In fact, though, us primary care docs are overworked and don’t have much time to deal with such paperwork. If we deny that the patient needs it, especially after their podiatrist already told them they do, the patients get mad at us.

I think the best way to minimize fraud would be to have patients pay a portion of the cost, say 25%. That way they are less likely to get a shoe or insert unless they feel they really need it. Actually Medicare pays 80% of the allowable amount so patients pay up to 20% if they don’t have secondary insurance. Since most patients are going to buy a pair of shoes in any case, I think they should pay what a similar non-medical shoe would cost, and Medicare would pick up the difference. That way there would be no financial incentive for patients to get shoes they don’t really need, and doctors could stop being the watchdog.

At the very least, Congress should allow nurse practitioners and physician assistants to do the paperwork.

Prior Authorization – License to Kill (our time)

A patient of mine informed me that her insurance didn’t want to cover a medication, and preferred a similar generic medication, which she previously tried but did not tolerate. She asked me to Call Humana’s  pharmacy review board. I usually leave such things to my nurse, but called them myself. A voice recognition system asked me for the patient’s account number and date of birth. After providing these, I was connected to a human, who asked for the same information. When I pointed out that I had just supplied the information, she said it didn’t come through, but made no offer to investigate why not.

If their menu system is not capable of transmitting such information to the computer screen of the people working for them, then they should not ask for the information using the automated system in the first place. This was not a onetime glitch, but something the nurses in my office encounter regularly. Our time is valuable. It’s bad enough that we have to justify our prescriptions, but it’s disrespectful of our time when we have to repeat ourselves with patient identification information. We have better things to do with our time.

Before deciding to post this, I decided to call again and give them a chance to say they would try and improve things. First I went to their website and clicked the For Providers link. I didn’t want to have to register, so I clicked the Customer Support button. Next I clicked the Contact Humana button. At the top it said they welcomed email, but one had to register to send messages securely. So I called their phone number for providers. Someone answered and wanted my patients ID number and date of birth. I informed I just had a question about the pre-authorization process, and not about a particular patient. She said that was another department and she transferred me, but not before asking for my name and call back number (I gave her my name, but told her I didn’t want a call back).

The next person again asked for my name and call back number. I explained my concern about being asked for the same patient information more than once. “That’s the process we’re required to follow,” she replied. I asked if they were interested in improving how they do things and she repeated what she had said. I asked if I could talk to someone who could improve the process. She told me they don’t have such a person!

I hope Humana and other pharmacy benefit managers take note. It may be your job to save your customers money, but you don’t have to waste physician’s and their office staff’s time. I hope the cynical view, that you do on it purpose to discourage prior authorizations, is not true.