• Rosalind Kaplan, MD

A View From the Other Side

A few days ago, I made a call to my neurologist's office. The fourth call about the same issue. I needed my migraine medication and wasn't able to get it. I was almost ready to give up and just give in to having migraines on a daily basis. None of the 'usual' preventative medications have worked for me, so I am on one of the new, hi-tech injectable medications for migraine prevention. It's a once a month injection, and after two doses, I do see a decrease in the number of headaches I'm having each month. The first two doses were free, shipped to me by the pharmaceutical company as a trial, but the third dose and beyond need to be obtained from a commercial pharmacy. That means the pharmacy needs a prescription from my doctor, and the medication needs to be paid for, preferably by my health insurance policy, as it is quite expensive.

My doctor's office had told me, when he first prescribed the medication, that it needed a 'prior authorization' and that they would begin working on that, so by the time I needed my third dose, my insurance company would be on board. I started working on getting the third dose right after my second dose: I called my doctor's office to find out the status of the prior authorization and to ask for a prescription to be sent to my pharmacy.

On that first call, I was told that the prior authorization had not yet been requested, but that they would do that now, and that the prescription would go to the health system's pharmacy, who would contact me as soon as my medication was available. Then they would ship it to me, as I live a distance from there. I was skeptical. I'm usually in the position of having to initiate that prior authorization, and I know how those things can slip through the cracks. I asked what I should do if I didn't hear from the pharmacy.

"If it's a few days before your next dose is due, and you haven't heard anything, call us back," I was told by one of the nurses.

Of course, time went by, and I found myself calling the doctor's office again a few days before my dose was due. I waited for the prompts, and left a message for the nurse. I also sent a message to my doctor through the patient portal, which states that messages will be answered within 48 hours. Seventy-two hours later, I had heard nothing.

I called my doctor's office again, and this time, pushed the prompt to make an appointment, rather than the prompt for medication refills or messages for the nurse or doctor. This way, I was assured of getting a person. I did, but she told me the nurse would have to call me back, and would do so by the end of the day. The reason my messages had not been answered before, she told me, was that the office received too many messages about these sorts of things, and were behind in responding.

The next day, the day I should have taken my medication, I called again since nobody had called me back.

"This time, the receptionist said, "I see by the notes in your chart that you are supposed to pick the medication up from the pharmacy."

"Oh," I replied. "Nobody told me that the medication was available."

"Let me check with the pharmacy," she replied. "Hold on."

A few minutes later, she returned to the line.

"Your insurance won't cover your medication," she said. "But the pharmaceutical company will cover another month, so you can still get your medication. Just pick it up from the pharmacy."

"Are you sure? My insurance told me they'd cover it. And I was told that the pharmacy would mail it to me, as it takes me an hour to drive there."

Oh, God. So I am going to get one more dose, and have to drive an hour to pick it up. Then what about the next dose? I would have to call my insurance and fight over this. The last time they denied something, it was for a family member, and was something that clearly should have been covered. I spent hours, over several months, solving the problem. I got at least 5 different explanations of why it was denied, until finally I told the representative on the phone that I was quite sure they were wrong, and I would have an attorney from my husband's employer call, since the insurance contract is through his employer (a health system). I got a call back minutes later from the insurance company, telling me that in fact, the insurer was in error, and the item was covered all along. They were sorry for the inconvenience.

"That's what the pharmacy said," the receptionist told me, in reference to my migraine medication.

I asked for the phone number for the pharmacy. I thanked the receptionist, and hung up. I knew I needed to call the pharmacy myself. When I finally got the pharmacist on the phone, she told me that

1. my insurance was covering my medication 100%, with no copay. 2. That they had been trying to call me but the doctor's office had given them a wrong number, and 3. That they would happily ship the medication FedEx, so my dose would only be 2 days late. She was sorry for all the miscommunication, and had no idea who the receptionist had talked to. The information the receptionist gave me was incorrect.

I just told you a long, annoying story. It turned out ok in the end. My medication arrived and now the pharmacist knows my phone number and will call me each month to let me know she's shipping the next dose.

The reason I tell the story, though, is to demonstrate how difficult it is to be a patient in need of care in the modern medical era. As a physician, and someone who is very well acquainted with the insurance system and health systems, as someone who is sophisticated about medical conditions and treatments, I am an excellent advocate for myself and my family members. Still, I get mired in red tape and misinformation. Despite my knowledge, getting what I need is not easy.

So if I have these problems, what about the average patient? The average patient in the current medical climate often does not know how to get a human on the phone at a doctor's office. The average patient is not sure what to do when he has left several messages and has not gotten a call back. He likely does not know what the insurance company ought to cover, or what they don't have to cover, or why. He probably doesn't know what to say when a legitimate claim is denied. The average patient, after enough nonsense, may well give up on getting his needs met, or he may get so anxious or upset that he starts yelling at someone who may be trying to help, but is, like my doctor's receptionist, misinformed. If that patient is feeling sick or has a serious condition, real harm may be done when medications or other treatments are delayed or discontinued. And the sicker the person is, the harder it is to wade through the all the bullshit.

My doctor has done everything he is supposed to do for me: he has diagnosed and treated me. He is supportive in every possible way in my quest to decrease my headaches. He is following my progress. He filled out the paperwork he needed to so that I could get my medication. The nurse in his office meant well; she told me what she knew to be the truth about getting my medication. The receptionist, too, tried to help. Even the insurance company did their part this time. The problems? A clerical error that sent the wrong phone number to the pharmacist, and misinformation relayed by someone in the pharmacy to the receptionist. Essentially, a breakdown in teamwork.

My husband, among other things teaches a curriculum of Inter-professional Education for the health system that employs him. The idea is to have true teamwork amongst doctors, nurses, ancillary staff, pharmacists, and other health professionals who care for patients. The goal is to achieve real team-based care. It requires excellent communication between all the parties who are involved in getting the patient better, from the person who checks the patient in at the desk, to the person who diagnoses and treats, to the person who hands a medication to the patient or performs a test the patient needs. This kind of team-based care is very different from our old model of care, in which the physician essentially owned the care of the patient, and everyone else was support for the physician. In team-based care, everyone on the team has ownership of patient care; everyone is engaged, and everyone is important.

Physicians can't own it all anymore. There are too many moving parts, too much technology, and too many administrative tasks in our oh-so-complicated medical system. Computers, the bane of many a physician's work life, can help the coordination of care through information-sharing, but there is no substitute for face-to-face communication between team members. Direct, respectful communication between team members can ensure that patients actually get what they need, by both spreading the workload so that the best person for each job is actually doing that job, and by taking misinformation out of the equation.

The hope: less burnout for professionals. Less stress for patients. Time and money saved. Better patient outcomes.

If my doctor's 'team' acted as a real team, this might have been the scenario around my migraine medication: the doctor lets an assistant know that the medication will be needed and when. The assistant immediately puts in a request for prior authorization and follows up on it. When the authorization is received, that assistant sends the prescription and the authorization to the pharmacist, along with patient information, and contacts the patient to let her know the authorization is done. A note is placed in the chart that the prescription is authorized and has been sent to the pharmacy.

Maybe a second person checks the patient information to make sure it is correct. The pharmacist fills the prescription and a clerk at the pharmacy contacts the patient. The medication arrives in plenty of time. There are no frantic phone calls from the patient, and no duplication of effort. The doctor and nurse don't need to leave their patient care to deal with minutiae. The nurse even has time to call the patient to find out how the medication is working, and relay that information to the doctor. If everyone does his or her job with every patient, there are less phone calls to the office, and important messages get answered promptly. Everyone is happier, and hopefully healthier.

Inter-professional collaboration and communication is, I think, one of the keys to turning our mess of a health system around in this country. It is a way to stave off many of the frustrations that both health professionals and patients are experiencing on a daily basis, and a way for everyone to feel more supported in their roles. The few doctors I know who work in clinics with true team-based care models describe feeling more positive about their clinical work. Hopefully this model will spread and become the norm. Maybe I'd have less headaches, and so would my doctor.

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