Every day I practice medicine I get a new story.

Today I attended a "pod group" meeting over lunch.  Billed as meetings of primary care providers hosted by our local medical group to allow us to get together and share items of importance to our practice, the meetings instead have degenerated into coaching sessions about how to "code" patient encounters in order to maximize income, for the medical group and, secondarily, for us.

The care provided by family practitioners, pediatricians, and general internists--primary care providers-- is known to be the most cost effective in medicine.  We know our patients.  We understand where they are coming from.  We can use this knowledge to tell, often, when a belly ache is a sign of serious disease, when a serious investigation is needed, or when reassurance and a little "tincture of time" is all that is needed.

You might think that the knowledge of the cost effectiveness of primary care would lead to comfortable salaries rewarding us for the money we save the health care system as a whole.  But it just isn't so.  Primary care providers are the lowest paid of all physicians. 

So, on a Tuesday afternoon, for an hour at lunch we sat and listened to the medical director of our group explain that we could earn another $500 apiece next year if we made sure that our asthmatic patients all (actually the cutoff for the bonus is somewhere over 95%) received preventive medication in addition to any medication needed for treatment of asthma exacerbations.

Supporting proper use of medical knowledge in this way is a new thing in medicine.  It is called "pay for performance" and among those who apply business models to medical practice it is thought to provide incentive to get doctors to do the right thing.  A long digression could review the scientific literature which has sought to test this assumption (summary:  the evidence of benefit is dubious), but I am really just introducing the concept to lead to the ironic tale of the day....

After I'd had enough of this meeting I returned to my office and was entertained by the first message of the afternoon.  The mother of a 20 year old patient of mine, a young man with mild but persistent asthma, called.  For many years his problem had been well controlled with only a single oral preventive medication taken once daily.  Without it he had need for periodic "rescue" medication. With a recent insurance change (from Health Net to Anthem) his medication was no longer covered.  Despite my "prior authorization" request, the insurance company had denied him the medication which had kept him stable for years.

Instead, their rules required that he first try and fail any of a number of alternatives, including "a long-acting beta agonist".  The irony of these rules lies in the fact that the use of a long-acting beta agonist would be in direct conflict with the message of our noontime meeting, a clearly inadequate and counterproductive alternative.

But I caved in.  I wasn't prepared to fight another windmill today.  I wrote a prescription for an alternative (not the long-acting beta agonist, but an inhaled preventive drug), discussed the change with my patient's mother, and let her know that I'd go to bat for the previous prescription that we knew worked if this alternative didn't.

I don't object to doctors getting a kick now and then to prescribe cost-effectively and to practice state of the art evidence-based medicine.  I pride myself in trying to do just that.  (Thus a five-minute addition to one visit today to explain to an eighty-eight year old obese woman with controlled cholesterol that she didn't need a blood test every three months!) But that a change in insurance resulted in:

-- a patient's losing access to a medication that works,  

-- the need to complete the paperwork for an ultimately rejected prior authorization request,

-- the need to explain all this to his mother,

-- a patient having to try a new medication which may not work as well as the one he'd used in the past

just doesn't seem right.

What we need in this country is a simple single health plan for all.  Let's take the new President at his word and let him know what we think.  Here's his suggestion line: http://change.gov/page/s/healthcare.  And here's where you can get more information about the change we need: http://pnhp.org/ .