Fed-up doctor sidesteps insurance company limits He breaks rules, citing patient care

Boston Globe ^ | June 11, 2006 | Christopher Rowland

[Jim Noble]

FRAMINGHAM -- When Tufts Health Plan cut a patient's prescription for the sleep aid Lunesta from 30 pills to 10 pills a month, her physician, Dr. Stephen A. Hoffmann, decided to circumvent state regulations by writing a second prescription in the name of her husband so she could get 10 more pills per month .

Hoffmann is aware that by publicly acknowledging the prescription ploy, he could be subject to disciplinary action and ... criminal charges. But he considers himself a ``medical conscientious objector," and says patient's welfare comes before what he believes are unreasonable insurance restrictions...

But the head of the Massachusetts Board of Registration in Medicine , the licensing authority for the state's physicians, said writing a prescription for someone other than a patient constitutes insurance fraud and violates the board's prescribing rules. Hoffmann could face a range of sanctions, from warnings to fines to license revocation...

With regard to insurance company restrictions, he said, ``It's becoming increasingly clear to me that the system is badly broken. A lot of my colleagues are demoralized, angry, and frustrated. Rather than . . . moan over late-night coffee in the corridors of the hospital, it's time to convert our dedication to our patients into a more constructive stance."...

But another ethicist, George Annas, said Hoffmann has an obligation to work within the boundaries of the law. ``He's not the only frustrated doctor in Massachusetts," said Annas, who is chairman of the department of health law, bioethics, and human rights at the Boston University School of Public Health ...

Hoffmann said that he understands that insurance companies and hospitals are trying to rein in a healthcare system bloated by runaway costs, but that he is responsible for providing the best care he can, not helping to restrain spending by insurance companies...

[TheBattman]

A couple of observations...

#1 - INsurance cmopanies do often pressure Doctors to be conservative in their treatments to save money. This can be good or bad - sometimes Doctors are too anxious to try the "latest and greatest" when the older tried-and-true method of treatment is still effective (and less expensive).

#2 - Writing a prescription in her husbands name was not just against the insurance regulations - it's AGAINST FEDERAL LAW. This was not the appropriate way to deal with the perceived problem.

#3 - This Dr. is missing something if he feels that his patient is in need of medication to sleep EVERY night.... Most medical professionals agree that constant use of sleep aids is addictive and harmful. I'm not sure how the insurance company came up with the magic number of 10, but subscribing 30 EVERY month is a bit suspicious.

[driftdiver]

"It's a vicious cycle between the carriers and the drug companies in that each are getting a piece of the action. "

I guess we can go with Hillary care and then everything will be broken.

[Polybius]

The insurance companies have had great success in making doctors feel responsible for what they will pay for, when in fact doctors have nothing to do with it. If Dr. Hoffman were to appeal every adverse insurance determination in a 2500-person practice, he would need to work at it 7 days a week and do nothing else. Is that a good idea?

Two totally separate issues here:

1. Pissing contest with the insurance company.

2. Prescribing drugs to a patient under a false name.

I will do whatever I can to help you in my medical practice but I WILL NOT break the law for you.

Dr. Hoffman used extremely poor judgment and traded the moral high ground for the illegal quick fix.

Dr. Hoffman's job is to practice good medicine legally. What an insurance company pays for in return for X premium dollars is a business transaction between the patient and the insurance company. By resorting to illegal prescribing, Dr. Hoffman is actually enabling the insurance company to survive in the market place with such practices instead of exposing the insurance company to the ire of its customers in the free market.

[cva66snipe]

Why can't her doctor prescribe something cheaper? My insurance company would not pay for my Ambein, When I found out who much it cost, I filled half the prescription. I found out the stuff was worthless. It made me hyper and kept me awake. My doctor switched me to tarazdone (200 mg every night)and for $7.00 per month, I sleep great most nights.

You're lucky. If me or my wife takes Trazadone we will likely end up in an emergency room in a psychotic state. They are very different drugs. SSRI's must be used with caution and the doctor was right to try you on Ambien first.

As for me and her we prefer Xanax 4 times a day low dosages. Most doctors would be outraged but most doctors do not dispense Xanax correctly which is the key to it's long term safe use :>} She's taken it 20 years and myself for 12 years. No problems. Just don't give either of us any type of antidepressants. You would not believe the battle I had with doctors and insurers to get xanax. Most doctors only acknowledge traumatic induced forms of anxiety and ignore sensory receptor/processor/motor damage as a causes anxiety. Give these types of patients Trazadone, Paxil, Zoloft, etc to these patients and you have major problems far worse than the original underlying medical condition. Yet insurers push SSRI's as a primary treatment. I buy our generic Xanax which is a fraction of the cost of any SSRI.

[goldstategop]

You know when you're a doctor and you're trying to use your medical judgment to help a patient and some insurance company bureaucrat decides its too expensive, that can really lead to questioning what's become of medicine. Who do doctors work for? That's the real issue under dispute here.

(Denny Crane: "Every one should carry a gun strapped to their waist. We need more - not less guns.")

[The Great RJ]

Insurance companies are basically practicing medicine wihout a license. My insurance plan has a "step" formulary that requires patients to start with the very cheapest generic drugs for conditions like hypertension or depression. Only if the drug is proven to have been ineffective after a minimum of six weeks of treatment, verified by a written doctor's certification, will the patient be approved for a more expensive dug at the next "step". No one cares if the patient commits suicide or has a stroke or suffers kidney damage while finding the right drug step. Many patients will also be financially coerced into taking cheaper drugs that might be effective but have life altering side effects solely to save a buck.

[Abby4116]

If every doctor didn't have to practice in CYA mode, all costs would be lower.

Patients (either individually or through their employers) pay ever rising premiums to the insurance company. The insurance company decides what is necessary care. If the physician fails to order something that may not be medically necessary (and the insurance company can shoot it down) and virtually anything happens to that patient, the doc has a pretty good shot at getting hit with a malpractice suit for "omission".

The patient, who has paid that hefty monthly premium, sees a "benefit" being cut - in the cited case, a prescription medication - and complains to the doctor who has, for whatever reason, in his best medical judgement, prescribed that medication.

[cva66snipe]

You're exactly right, except it's not really a Ponzi scheme. It's a novel legal structure, authorized by Congress, where "A" (patient) makes a contract with "B" (HMO) to allow "B"s normal liability to be transferred to "C" (the doctor). "B" then does what would be illegal if "B" were practicing medicine, and tells "A" to complain to "C". I do agree they are doing all this to cause the system to collapse. It's been remarkably resilient, but probably can't exist for more than 5-7 years more.

I've been fighting against this system ever since it started. When Gore, Hillary, and out then Dem governor decided to turn the state Medicaid program over to HMO's Blue Cross/Blue Shield ran full page scare adds in Tennessee papers saying the health care sky was falling. They also forced via threats their doctors to either sign on to Tenncare or not see BC/BS patients. BC/BS ended up with the majority of Tenncare contracts as well. The system nearly bankrupted the state.

Dealing with Tenncare HMO's just trying to get basics nearly did me in a few times it was literal cussing matches with them. But I have never lost though. They end up paying but you have to be willing to fight them.

Placing the disabled into an HMO is at best foolish if not cruel. It is definately not cost effective. You'll understand what I'm saying. We receive no outside help. I am a caregiver. No home health and the number of times we've had home health visits in 21 years I have more fingers and toes. I've done it all from changing Folley's to treating stage 4 skin ulcers. Yet they want to nickle and dime us out of health care?

My wife's situation is serious she's a duel ostomy by-pass patient and a quadriplegic. I'm the walking disabled. A very dysfunctional Vestibular and visual processing system setting of sensory induced G.A.D. {non phobic} with Myoclonic Seizures as an extra added bonus. Give me my Xaxax and P&Q and I'm functional.

[cva66snipe]

An interesting article on how Tenncare was put in place and relative to this thread in many ways. TennCare: The Perils of Cost Containment

[netmilsmom]

I also agree with you to a point but some of it is not negotiation but rather extortion.

SuperBlue was notorious for this. Refuse to pay for a patient until so much paperwork was put out that ANY payment was better than nothing.

The idea that insurance companies are helping anyone but themselves, is silly.

[au eagle]

Yes, and with the new Medicare drug plan schemes, the "step" program can be a replication of what a patient has already done. IOW, the physician, years earlier, had tried cheaper alternatives only to find they did not work for the patient. It is very frustrating being told to do the "step" program as mandated by the drug company when the outcome is obvious.

[Hildy]

I'm sick of it too. You have car insurance, but it doesn't pay everytime you take it for a tune up, or when the battery dies. It doesn't pay for new tires and it DOESN'T pay for gas. Why do people think they're insurance should pay for EVERYTHING. It pisses me off. SAVE YOUR MONEY FOR A RAINY DAY.

[Savage Beast]

These days, a doctor's gotta have guts to put patient care above everything else--as the vast majority want desperately to do.

Not only must they deal with government burocracy and laws that will make them criminals for such things as a slip of the pen;

Unless they are foreign doctors, who stash all their assets safely in banks back in their nations of origin and thus shelter them from confiscation by plaintiffs and their lawyers, they are sitting ducks for financial ruin.

Only saints can give their entire consideration to the care of their patients under such circumstances.

[pierrem15]

While it's true that the woman could have purchased the extra prescriptions herself, it's also true that she has a contract with the insurance company to pay at least part of the cost of what is "medically necessary".

What happened is that the insurance company's medical board has decided (without evver examining the patient) that the additional pills were not "medically necessary."

Normally, making a diagnosis without examining a patient would be considered malpractice, but because the insurance companies have putchased legal exemptions to being sued for such decisions from the legislature, they continue to make them.

It's the irresistable force of 'third-party payer' entitlement meeting the immovable object of insurance company and hospital legalized fraud.

We need to get rid of the notion that ordinary medical expenses like precription drug treatment must be largely paid by third parties, while also removing the ability of insurance companies to hide behind their medical boards and hospitals to engage in cost shifting.

[BJungNan]

All the insurance company said, if I understand this correctly, is that they are only going to pay for a 10 day supply per month, not a 30 days supply.

If that is indeed the case, the solution is really quite simple: The patient pays for the difference or works it out with the drug manufacturer and/or pharmacist to get the extra for free.

The option the doctor has choosen is the least acceptable path towards his goal.

[tubebender]

There is a Doctor here in Eureka Ca that does not bill Medicare and insurance companies. The patient pays $1,000 a year for office visits and he even makes house calls and has more time with his patients. He has eliminated his billing department and he seems to be doing well...

[meyer]

If my doctor decides I need a certain medication that is to be taken every day, and the insurance company, in their infinite wisdom, decides it only wants to pay for 10 days worth of meds, and leaves me with the responsibility of paying the balance, who's at fault?

Who's at fault? You bought an insurance policy that clearly states what's covered and what is not. Unless they decided not cover something for which they had contractually agreed to cover, it essentially would be your fault for buying insurance inadequate to the coverage you desired.

[ApplegateRanch]

I worked nights in a hospital for years, and sometimes needed a sleeper during the day.

I used 2-25mg generic diphenhydramine---Benadryl, for those enamored of brand names---the same as our patients received in well over 90% of cases.

When I spent two weeks in-house for surgery, that was the prescribed sleeper I was given, too.

Works great; cheap; available in bulk at Wally-World, Costco, etc; strictly OTC.

NOTE: THIS IS PERSONAL ANECTDOTAL EXPERIENCE, NOT MEDICAL ADVICE; I AM NOT LICENSED TO RECOMMEND NOR PRESCRIBE ANY MEDICATIONS.

[peggybac]

Why the hell are insurance companies paying for sleep aids? There are plenty over the counter pills - even benadryl capsules if you like. Geez Louise this makes me angry.

[ApplegateRanch]

You paid the 900 on the first charge. The insurance company probably got the bill reduced by a certain amount and paid less than 4500. Did you see the final bill?

Is it not fraud on the part of either the insurer or the practitioner for the insurer (depending how the bill is paid by the patient, to whom) to pay a reduced final bill, but the patient to not recieve a refund of the difference between the 20% of initial & final billings? Otherwise, the insurer is NOT paying the contracted "80%".