December 11, 2005

So Ends The Ochlocracy of Medicine: How To Fix Medicaid, Part 1

Preferred Drug Lists are the bane of the practicing clinician. Instead of, for example, a psychiatrist being allowed to prescribe any antipsychotic they think appropriate, Medicaid requires them to pick from a list of only three, "on formulary" agents.

Unfortunately for doctors, the logic is sound. Unless one can show that, for example, two antipsychotics do not have the same general efficacy or tolerability across a population, than an insurance company cannot be reasonably obligated to provide both, especially if one is cheaper.

Psychiatrists complain that some patients respond better to one drug than another, but while this may be true, there is no way to predict this; try the formulary ones first. But this is just a red herring. What angers doctors is that these restrictions are an intrusion on their practice. Doctors are better able to decide risks and benefits of a medication; which drugs to prescribe, and when.

This would be a great argument if it were true. It isn’t.

The truth is that doctors are woefully ignorant of the available scientific data. As with literature and philosophy, most doctors read about the science, not the actual science itself. In general, doctors prescribe medicines not based on careful review of data, but impulse, habit, and the recommendations of “thought leaders.” (Seriously. They’re actually called that.) Prescribing medicines based on partial information or clinical soundbites may feel like "the art of medicine" but it is, in fact, a random process. It is certainly no better than having an insurance company that did review the data tell you what not to prescribe.

They also tend to practice in a vacuum. A patient’s psychiatrist and cardiologist have no link. Are the treatments synergistic? Antagonistic? Neither fully know that the other is doing.

And so, because doctors are not rigorous about their practice, someone else has to be. One of the most outrageous way psychiatrists, and possibly other physicians, waste money is to use multiple medications for a situation that could well have been handled by one. “Polypharmacy” is so common that it is actually codified in treatment guidelines, despite—and this is where insurance companies go insane—there being practically no evidence that this is ever appropriate. Why combine two antipsychotics when maybe more of one will do? It may seem plausible that two are better than one, but they aren’t. It may be true that a patient needs two drugs; but you can’t assume that. The default practice cannot be augmentation. That has to be the maneuver of last resort.

Loose practice has caused the paradigm shift. It used to be that everyone deferred to the judgment of the wise physician. No more. Now, it’s incumbent upon us to show why we need to use a treatment, not for the insurance company to trust that we know best, that we made a careful analysis of the risks and benefits—because we didn’t. We complain that medicine is being assaulted in a million different ways—insurance companies, lawyers, alternative practitioners—but the reality is it is the exact same assault: we are no longer trusted to know best.

So what to do? There is a solution. But you’re not going to like it.

Link each Medicaid patient with a pharmacy budget per specialty—money controlled by the psychiatrist. A psychiatrist can use any drug, any dose, no restrictions, but only up to, say, $10 a day. Go.

There are numerous advantages.

First, there is cost control.

Second, Pharma will inevitably cut prices in order to compete.

Third, it gives doctors their autonomy.

Fourth: it will force doctors to pay very close attention to what is, actually, best practice. They will have to be more attentive to outcome studies. They will have to predict side effects: if you’ll need to add a second drug to counteract the side effects of the first, it may be better to use a completely different drug.

Fifth: They will use fewer medicines. Two is not always better than one; but it certainly is twice as expensive with twice as many side effects.

Sixth: Pharma no longer has incentive to create “me too” drugs. They are incentivized to come up with novel, even niche, treatments.

If you really want to tax the imagination of doctors, and force a level of rigor in medicine that has not been seen since, well, since never, create a global pharmacy budget per patient across all subspecialties. This way, if a psychiatrist wants to prescribe Zyprexa, he’s going to have to discuss with the cardiologist whether that is more cost effective than the Lipitor. Wow.

The unexpected benefit is that the two doctors have to communicate. Maybe a switch from Zyprexa could preclude the need for Lipitor? Maybe? Hello? Let this communication be billable to Medicaid. $100 per “consultation” is more than offset by the pharmacy savings. There are going to be some patients who actually do require more money, more medications. In that case, the doctor can petition for increased benefits. Doctors hate doing this. Too bad. The problem was created by doctors, not by pharmacists.

Finally, to bring Pharma into the game: the first 30 days of a prescription must be piad for by the Pharma company making the drug, i.e. samples or vouchers.  This way, only the drug that actually works gets paid for by Medicaid.  That's gold. 

It’s worth stating, for the record, that I am opposed to government interference in my practice. I don’t particularly like lawyers, either. But the sad truth is that the state of psychiatry is the fault of psychiatrists, who have failed to take full responsibility for their own education and practice. To blame anyone else at this stage is totally disingenuous.


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March 23, 2007 11:08 PM | Posted by insurance homeowners ratings: | Reply

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Wow, I like that idea a lot... (Below threshold)

October 23, 2007 6:26 PM | Posted by ambrosen: | Reply

Wow, I like that idea a lot. Although doubtless it's susceptible to gaming somehow, at least it's not immediately obvious.

I agree it's a good one. And I've never met a doctor who liked it, ever. "What, should we be expected to monitor drug prices as well?"

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December 12, 2007 3:30 AM | Posted by bovinedefenestration: | Reply

This is why I'm considering going to pharmacy school before even considering med school. If I'm going to be taking care of peoples' health, I'd damn well better know about the drugs, and have the skills to know what they're really doing to my patients. I'm interested in neuropsychiatry, and considering the prevalence of drug usage in both fields I really want to have a handle on it.

The entire drug benefits system is ridiculous, I agree completely. I see everyone but my general practitioner at the University of Iowa Hospitals and Clinics, and one doctor can see the information for all other departments and consultation is easy in-hospital, and they can see what all medications I'm on. That was a deliberate decision, and more and more hospitals in the area are switching to hospital-wide systems. However, there is that nagging problem of communication between multiple practices, and it will be interesting to see what methods doctors come up with to be lazy. Heh.

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The problem described here ... (Below threshold)

June 20, 2008 10:37 AM | Posted by Cristian: | Reply

The problem described here is the same as the problems in an alcohol treatment because doctors seem to think that the solution to such a mental problem are drugs. Actually not... it was scientifically proven that therapy has a bigger and efficient influence over mental problems.

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March 20, 2012 11:08 AM | Posted by happy: | Reply

Wow that was strange. I just wrote an incredibly lengthy comment but after I clicked submit my comment didn't show up. Grrrr... perfectly I am not producing all that above again. Anyhow, just wished to say great web site!

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June 26, 2014 9:42 PM | Posted by c: | Reply

There's no longer comment capability on your previous post.

I just wanted to say this is my favorite blog of all time and I am now starting from the beginning.

And God loves you

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I'd upvote you if that func... (Below threshold)

June 26, 2014 11:00 PM | Posted, in reply to c's comment, by johnnycoconut: | Reply

I'd upvote you if that functionality still worked. Good luck in reading this whole blog (and some of the comments are really good as well). There's also a previous version of this site on Web Archive that was exclusively psychiatry-focused and contains a few early versions of posts that are still up, among other things. On Web Archive, you can also find deleted posts like "But I Wanna Kill Myself," which aimed to discourage suicide from a Kantian perspective but then got suicidal comments, and some "Terrible Truth About..." posts. There are also some good, mostly short, posts on Partial Objects if you aren't familiar with it already (TLP's posts there are usually among the best, but there are some really good posts there from others). Have fun!

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I started reading Partial O... (Below threshold)

June 27, 2014 8:52 AM | Posted, in reply to johnnycoconut's comment, by johnnycoconut: | Reply

I started reading Partial Objects a while ago. I'm not close to done.

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June 27, 2014 2:30 PM | Posted, in reply to johnnycoconut's comment, by Anonymous: | Reply

I like TLP but I'm kind of glad he deleted it. Upon looking it up on the Wayback Machine, it's one of his worst-written articles. I appreciate that psychiatrists are the last people who should encourage the notion of suicide, but the conclusion pales in comparison to anything written by Schopenhauer.

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