Prescribing physicians who do not “get it”

As mentioned yesterday, according to CWCI’s research, 10% of the physicians in California that prescribed Schedule II drugs accounted for nearly 80% of all prescriptions in 2011.  Take that 10% and add in those that dispense from their office (where the treating physician actually has a financial interest to maintain and even grow pill counts) and physicians who are not interested in other people’s opinion.  That leaves about 65% of physicians who are willing to make changes to an inappropriate drug regimen based on Evidence Based Medicine (EBM) and a collegial dialogue with a peer (this is the rate since 2010 in which our reviewing physician can reach agreement with a treating physician on changes).

So the struggle is with the approximately 35% of treating physicians who are not interested in cooperation (whatever their motivation).  I’ve heard of a variety of strategies:

• Force thru Utilization Review: If the treating physician will not cooperate in a collegial, voluntary manner then enforce UR at the pharmacy Point-of-Sale (POS) and do not allow inappropriate drugs to be dispensed (or when third-party billed, deny payment based on UR).  This puts the treating physician and patient on notice they will need to appeal and prove why the drugs are appropriate.
• Depose the doctor: Under oath, ask the treating physician for their clinical rationale for continued use of drugs that EBM and peer review view as inappropriate.  Assuming recommendations have already been rendered utilizing EBM, science should trump “because it helps the patient” without objective proof that the patient is getting better or has truly reached Maximum Medical Improvement (MMI).
• Change the contract: The State Compensation Insurance Fund (SCIF) in 2011 modified their MPN contracts to require a physician to limit prescribing opioids for no more than 60 days.  This is very similar to Washington state requirements that require a "second opinion" on aggregate dosage exceeding 120mg MED, and the Texas Closed Formulary that requires preauthorization of an ODG "N" drug.  However it is implemented, requiring a "deep breath" before starting down the path of highly addictive drugs is common sense.
• Pursue legally: There are currently attempts underway to pursue legal and malpractice action against physicians who truly practice bad (and dangerous) medicine in California.  Interestingly, an article this morning in workcompcentral (requires subscription) documents a Chicago physician, Dr. Paul H. Volkman, who has been sentenced in Ohio to 4 life terms in prison because of the overdose deaths of four of his patients between 2003 and 2005.  A representative of the Texas Medical Association mentioned three weeks ago that "quality of care" issues should be reported to the TMA for action against the physician.  Bad outcomes should trigger bad consequences.

There are other, creative, methods being used in California (and every other jurisdiction) to address these “bad actors”.  As government leaders are prone to say in difficult circumstances, “all options are on the table”, and to me the only bad idea is the one that has been tried and failed.

In this together – Mark

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