Christopher Adams MD

Think about the last time you really pushed your muscles to the point of anaerobic lactic acid build-up (some of have to think back longer than others). 

Now, think about times you have said, “My 

. We call it “brainpower” because the brain needs glucose and expends effort in order to think. There is 

from what shoes to wear through what way to get to work and which test to order on a patient, all require a 

nickel here and a dime there of mental energy

. Consider what you must think about during the clinic day: collecting clinical data via the traditional H&P, entering data and checking meaningful use boxes in an EMR, keeping up with what Part D formulary allows which biologic modifier medication, etc. with redundancy.

14 clicks to send a single prescription from my EMR 

– let’s call that 14 cents of mental effort. Like cable TV bills, the

: “…due to the government requirements of the EMR, 

.   Have you seen an ER note lately? Typically 20 pages long…with 19 pages of formulaic detritus.”

Our cognition is literally being nickeled and dimed all day. Every time you do something related to health care delivery, like clicking a meaningful-use box or taking the extra steps needed to send a prescription, you have that much 

less mental energy to use thinking about your patients' health care.

 decision fatigue, and decision fatigue leads to 

 Providers know the guidelines, but studies now shed insight on why we don’t follow them, and it has to do with cognitive fatigue. More 

 in an emergency department occur on the 

, and more deviations from prescribing guidelines happen in clinic 

 can also deplete our mental currency: EMR pop-ups can lead to 

 suffer from information overload in selecting articles to publish.

Even taking a lunch break seems to matter. A study showed that judicial decisions were often different before and after the 

It makes sense for us to use our mental energy where we need to spend it most: taking care of patients. 

How can we deal with the nickel-and-dime costs 

that healthcare delivery places on our cognitive currency? I’ve been thinking hard about this, and 

 follows your practice workflow efficientl

y. Don’t let start-up cost be your sole focus. Spend the time mecessary to analyze how much the EMR forces you to follow its rules. Find out whether the software can be modified to meet your particular needs. The day-to-day high costs in time and mental energy of a 

poorly functioning EMR can make a low-cost, sweet-deal system into a real lemon

 to support staff. We deal with the myriad formulary differences of various insurance plans by having a trained medical assistant whose job it is to stay current with formulary changes, or to contact the pharmacy representative for assistance.

avoid interruptions during a patient visit.

 There will always be true emergencies, but have protocols for dealing with potential interruptions that every member of the staff understands. We schedule specific breaks during clinic so we can catch up on “urgent” issues without interrupting patient visits.

; Not a huge lunch that will blow your diet and ruin your youthful figure, but just a quick snack.

 and take advantage of it. A psychiatrist I know takes a 20-minute 

 He jokes that it gives him the power he needs to deal with his “crazy” afternoon clinic!

A busy medical practice may still leave you feeling exhausted at the end of a day, but you can feel better about that fatigue if you know that your mental energy was not wasted on trivial matters.

Articles

Are you letting meaningless details squander your mental currency in rheumatology practice? The author points out how to recapture energy stolen by mere paperwork that should be used on your real job: Patient care.

Five Ways to Conquer Cognitive Fatigue and Meaningless Use

[[{"type":"media","view_mode":"media_crop","fid":"32176","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_3955334910663","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3404","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 213px; height: 109px; margin: 2px; float: right;","title":" ","typeof":"foaf:Image"}}]]I used to treat some fighter pilots. They all hated paperwork. One of them told me, “Doc, when the weight of the paperwork exceeds the weight of the airframe, you are finally cleared for takeoff.”

I laughed at the absurdity of this, and dismissed the hyperbole as fighter-jock bravado.

Today I appreciate the metaphor, because the same 

paperwork burden now hinders us physicians from fighting disease.

  In thousands of practices across the country, many times a day, insurance company pharmacy benefits managers 

(PBMs) either demand that we justify our therapeutic choices 

by asking for prior authorization (PA) or outright 

etter from two members of Congress to Express Scripts

 about some of the biologics used in rheumatology.)

PAs relate to “step-edits” or “fail-first” rules, which 

force patients to try cheaper or “preferred” drugs before the PBM will pay

 these delaying tactics are really cost-control measures.

only for the “big ticket” items like chemotherapy or biologics

 that cost hundreds or thousands of dollars a month.  Most of us accepted the 

 of these cost controls. After all, the insurance company needs to give the greatest good for the largest number of beneficiaries using finite premium dollars. This may be at odds with my desire to do the most good for the individual sitting in my exam room, but the model is at least philosophically defensible.

principle has spread to even staple generics

: standard-of-care medicines like meloxicam, cyclobenzaprine, azathioprine, and methotrexate. 

Are all patients with rheumatic disease too expensive to cover?

Rumor has it that the largest insurer in my state will propose requiring PAs for 

, from inexpensive generics to the most costly biologics.

, from solo practice to big group to university mega-clinic. Although each doctor had a favorite personal gripe with PAs, several 

PAs are being demanded for inexpensive generic medicines.

American College of Rheumatology in numerous position papers

 switching patients from one NSAID to another

. (One insisted that tizanidine is [[{"type":"media","view_mode":"media_crop","fid":"32177","attributes":{"alt":"formulary police","class":"media-image media-image-right","id":"media_crop_2650587792314","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3405","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 143px; height: 147px; margin: 2px; float: right;","title":" ","typeof":"foaf:Image"}}]]safer than cyclobenzaprine for my 77-year-old who strained his shoulder playing tennis. That’s not what my pharmacology textbook says! But no amount of science will dissuade the formulary police.)

 Since each PBM has different criteria, completing PA requests is more complex than reciting the complement cascade backwards. A single 

PA for one patient may take 30 minutes or more

 of chart research, form completion, form resubmission, and phone calls. My quick survey suggests that PAs currently require 

0.77 full-time employees per practitioner

: 3 employees to do nothing but prior authorizations for 4 prescribing clinicians! Few practices can afford this expense.

3. Denials and delays impede patient care

. This speaks for itself. The longer an insurer can string out an approval, the fewer days it has to pay for the medicine. Many plans explain the delays to patients by saying 

“the doctor didn’t fill out the form right” – inexcusable blame-shifting!

4. Clueless clerks tell doctors how to prescribe

. This is my pet peeve. Last month I was told that I must use three aromatase inhibitors to treat a man with rheumatoid arthritis before the PBM would approve methotrexate.

 Give tamoxifen to a man with RA? Where did this policy come from?”

,” replied the customer service representative (honest and cheerful, but unrepentant). This is not only 

My respondents had a host of other complaints (some unprintable). But all agreed that the PA process as currently imposed on rheumatologists is simply unacceptable.

 how can we reach an understanding with PBMs

 that will meet patient treatment needs while allowing us to be good stewards of the health care dollar? I propose that any action be based on three principles:

1. Every PA pathway, step-edit, or fail-first policy 

conform to current standard of care practice guidelines

. Don’t ask me to use sulfasalazine as a prerequisite to TNF-Î± therapy in axial spondyloarthritis if the 

current published guidelines say it doesn’t work

! I should not be forced to practice substandard medicine because of a PBM’s cost constraints, or because their clerk can’t read medical journals.

. If a PBM creates a PA, it must be clear and applicable to the prescribed drug. (Please don’t tell me Remicade is a Part D benefit or methotrexate is part B). It must also be willing to offer unconditional approval when criteria have been met. (The PBM clerk must actually read the form that says their preferred step-edit drugs have already been tried.)

. If a PBM requires a PA, they must provide an answer within a few days, not weeks or months. Diseases damage joints while PBMs decide whether your patient (who paid a premium for care, and deserves to get it) is worth treating.

It’s all well to state principles, but how can we achieve them? ACR position papers are not enough. Hours on the phone cajoling insurance clerks is not the solution. Policymakers (insurance and government) won’t listen to experts like rheumatologists, because 

they see us as the problem: We write the expensive prescriptions.

 to pressure politicians and PBMs to implement these simple principles. Organizations already exist to promote this kind of advocacy (see 

), so we don’t have to start from scratch.

Draft a letter to your patients and hand it to them as they leave your office

.) Briefly explain the problem with PAs, direct them to an advocacy site, and ask them to do themselves (and you) a favor by writing their insurance company and their legislators about the roadblocks to reasonable care that PAs impose. (I've also supplied 

draft language for a letter from patients to their legislators

. You may want to add specifics regarding a particular problem with reimbursement.)

The policy makers may ignore the pleas of dozens of doctors. But 

they will listen to thousands of patients

 (a.k.a. “beneficiaries” and “constituents”).

draft letter from patients to legislators

, click the printer or PDF icon in the black bar at the bottom of the screen.)

Prior authorizations have begun to spread pandemic-like from high-cost biologics to treatments used routinely in rheumatology. The time burden on rheumatologists is insupportable, contends the author, who says it's time to take action.

Rheumatologists! Unite Against the Formulary Police!

Want to start a food fight? During a banquet at a medical convention, innocently ask the question: “

Is board recertification a valid measure of your professional knowledge and ability

Within minutes, asparagus spears, mashed potato grenades, and mystery-meat landmines will explode all around, as proponents and adversaries of the ritual called “board certification” express themselves in a scene reminiscent of the film classic “Animal House.”

proponents offer valid and logical reasons to continue 

 to distinguish true healers from hucksters

, for the benefit of both patients and physicians.

adversaries have marshaled over 19,000 petitioners calling for an end to meaningless metrics that lack validity 

and hang over them like a sword of Damocles,  threatening to sever them from participation or to reduce their reimbursement, using “quality” as a weapon.

Perhaps no other professional issue today creates such divisive and emotional battle lines, and has received such broad press coverage, from the 

As a rheumatologist in solo private practice in the under-served backwaters of a Southern state, I will venture into the no-man’s-land that separates the two warring camps and offer a dispatch from the home front of a busy clinical practice.

The issue arose recently at lunch in the doctor’s lounge

. (This being only lunchtime, no food was lobbed.) Everyone agreed that the current system is flawed, but solutions were as varied as the doctors who offered them.

•    A surgeon told me he liked the annual maintenance of certification (MOC) process, but he felt that an examination given every decade was meaningless.

•   An internist said almost the opposite: that ongoing MOC tasks cluttered an already difficult clinic day, but that the periodic examination stimulated continued learning.

•   One innovative hospitalist suggested that we test certification the way we really practice 21

 century medicine, by evaluating a clinical presentation using all the open-book tools of web searches and online textbooks that we 

 employ daily when facing a challenging patient.

and begin to clean the turnip greens from the wall and the ham hocks from under the chair?

When exploring a contentious issue, it is essential to identify agendas, so I will divulge mine.

 I want to provide my patients with the very best

, scientifically validated, cost-effective care possible. Y’all (remember, I am Southern) may be right there with me on that agenda.

least possible interference from third parties 

who lack my experience and education. (Some of y’all are getting nervous about my agenda now, knowing that we shall never rid ourselves of government and insurance regulators.)

demonstrate my ability in a meaningful way

This is where we lose ourselves in the smokescreen of 

what defines “quality” and what is meaningful

 in conflict: Regulators--and I include my esteemed colleagues at the American Board of Internal Medicine (ABIM) in that category--who revel in

 metrics that rigidly define “good” by the numbers

, and my physician colleagues, who understand 

quality as a symphony of characteristics that blend into a harmonious outcome

The metrics offer a simplistic binary outcome: Maintain certification, or not. Convenient, yes, but (as recent studies suggest) that metric lacks scientific validity to measure real differences in physician performance. Unfortunately, a qualitative measurement tool applied to all physicians might also become arbitrary, and would lack the rigor we expect from a validated instrument.

The smoke thickens. Let’s step out of it for a minute to ask a practical question: 

Does there have to be only one way to demonstrate quality? 

You would call me a fool if I advocated only one proper way to treat rheumatoid arthritis. So why should I embrace only one proper way to measure quality?

We can all agree that we want to provide optimum care, and we may agree that we want definitions of quality to be set by the people who care for patients, rather than by those who “administer health delivery.” Can we then agree on a best means to do this? Is it an electronic chart audit of how many patients I asked about smoking? Is it a two-day eye-straining marathon in front of a computer monitor, answering multiple-choice questions about renal biopsies and the molecular biology of presumed medication actions?

Old ways served us well when we learned from books and did not have access to a library at our fingertips. We do need

 new tools now for the new way we practice.

plead that we consider practicality in the resolution 

1. As a busy clinician in an underserved area with a months-long waiting list, 

please don’t demand long absences from my practice

. I can’t afford the overhead, and my patients depend on me. Do I really need to spend two days in a cubicle pretending I know how to interpret immunofluorescent-labeled skin biopsies? (If I did that in the real world, any lawyer worth his salt would sue me.)

2. In this age of iPhone apps and Wi-Fi connectivity, I would ask the ABIM to invest some of the money I pay for the privilege of recertification in 

software that allows me to show that I can recognize problems when they arise and ask questions

 real-time in the clinic. Go ahead, I dare you: Track my use of UpToDate and PubMed!

3.  As a scientist and a pragmatist, I would also insist that any means selected to 

measure my “quality” be subject to the same standards of significant outcome

. I want validated measures, because I don’t have time to waste doing busy-work just to satisfy someone’s educational theory or to advance a social agenda.

4.  As a consumer of goods and services, I would ask that there be

, because competition is good. I like competition, and our marketplace of goods and services depends on competition to best meet consumers’ needs. Far from creating confusion, having several options for demonstrating quality would benefit doctors and patients alike.*

So instead of trying to find a monopolistic “best” way to assure certification ,we should develop 

several, possibly competing, ways to demonstrate our value 

to our patients, to third party payers, and to government regulators so that we’re not just evaluated like soybean or pork belly commodities. We are capable professionals practicing the healing arts.

(As one esteemed member of this network’s Board asked in an internal email thread on the subject: “Is anybody of the ABIM listening?”)

(This article is the author's own opinion and does not reflect the opinion of the 

staff or that of its Editorial or Advisory Board members.)

For the importance of social policy having just enough choices, but not too many, see Thaler RH, Sunstein CR.

Nudge: Improving Decisions About Health, Wealth, and Happiness.

  New Haven CT: Yale University Press; 2008.

 MOC changes aim to lessen burden on physicians, but debate continues

Changes to ABIM MOC Requirements Stir Debate

 The ABIM Foundation, Choosing Wisely®, and the $2.3 Million Condominium. 

 Stop Wasting Doctors' Time: Board Certification Has Gone Too Far

(OPINION) A rheumatologist in solo private practice in an under-served area offers his prescription for protecting patients' interests in sound medical care as well as the time, professional obligations, and public image of physicians.

Author | Christopher Adams MD

Articles

Five Ways to Conquer Cognitive Fatigue and Meaningless Use

Rheumatologists! Unite Against the Formulary Police!

What to Do About the Maintenance of Certification Mess