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COLUMN: Who's between you and your doctor?

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COLUMN: Who's between you and your doctor?
Mitchell South Dakota 120 South Lawler 57301

How many times have you heard politicians say that no bureaucrat should come between you and your doctor? You and your physician should decide when you need to go to the hospital or when you might want to wait out that cold before taking an antibiotic. At least that's been the American ideal of the doctor-patient relationship.

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The reality is something very different. We are reaching a crossroads in this country in terms of physician autonomy, says Dr. Luis Collar who writes on the blog KevinMD.com. In an essay a couple of weeks ago, he wrote: "Despite the foul smog of competing interests that permeate this new delivery paradigm, one thing is clear -- physicians are no longer calling the shots." Collar is talking mainly about insurance companies and hospital administrators that are dictating what they can and cannot do.

Increasingly, all of us are waking up to that realization. For me, it's been happening at the pharmacy where a kind of rationing is taking place in how much medicine people can get at one time. A woman comes into my local pharmacy and asks why she can't get a 90-day supply of a medicine the doctor ordered. The pharmacist tells her the insurance company won't pay for 90 days, only 30 days.

Why? The pharmacist gives a couple of reasons. Insurers, he says, want to push people into mail-order pharmacies or pharmacy benefit managers, which might be able to supply the drug cheaper. If patients become annoyed, more of them might agree to get their prescriptions through the mail. He also said they aren't sure a doctor won't change your medication, so they don't want to waste money on something policyholders might not need or use. In other words, the insurance company is making the call about what you will need and when you can have it.

What about getting enough for a long vacation? The pharmacist gives a date when the prescription can be refilled -- but it's after your departure date. There's always the option of paying out of pocket for the drug. That might be OK if the price is $11 or $50, but when the retail price is $400 or $600, what's a patient to do? The Great Cost Shift that's taking place in American medicine -- from insurers and employers who pay the bills -- has come to your local pharmacy.

Here's more evidence of the change in doctor/patient relationship. Recently I received a letter from my own insurance carrier that suggested I needed a health coach "to get started on a healthier lifestyle." A nurse I could talk to once a month as part of a disease management program who, the letter said, could help me reach my best health by suggesting ways I could lower my cholesterol, or lose weight, or by helping me with serious conditions like diabetes.

"Because of your health history, we think you might benefit from joining our program," the letter advised.

What history? I don't have diabetes. I don't have a weight problem, and my cholesterol is normal. What did the insurance company have in mind for me? Were my eye medicines getting too costly for the company? Was the insurer trying to switch me to a cheaper medication? Did the insurer want to switch me to a different med? Eye medications are my biggest health care expense. Some are expensive.

I was annoyed by this intrusion, and called the number listed on the letter. A customer service rep told me I received "an outreach letter" to advertise the program.

After I told her no, she had one more question. "On our calls we have to screen everyone for depression," she said, and asked if I had been down or depressed in the last two weeks. This was over the top. If I were, which I wasn't, why would I tell a customer service rep pushing a service on the phone? You'd be surprised how many people say yes to that question, the rep told me. Does the insurer then send them to therapy or suggest anti-psychotic meds?

This tale reinforces my point. Medicine is no longer a matter between patient and doctor. As patients, do we still want such relationships, or are we willing to sacrifice them as insurers and other big stakeholders in the health care game push to change that in the name of cost containment?

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