Don’t punish all doctors to find a few dangerous physicians

One of the things that used to make physicians different from other providers is the ability to prescribe drugs.  This is not true anymore, but the majority of prescriptions are still written by doctors.  Prescribing practices of physicians vary widely across different populations and specialties.  If a doctor takes Medicare patients, his prescribing patterns are part of the mountains of data Medicare collects about it’s patients.  In 2003 the government passed an expansion of Medicare called Part D.  This program pays for prescription drugs.  35 million people have Medicare Part D.

ProPublica, the non-profit investigative reporting organization, says there’s a problem with Medicare part D.  It’s not that it was a bad idea, or that it costs too much.  The intention was good and it has cost less than it was expected to.  The problem seems to be that doctors are prescribing too many dangerous or inappropriate drugs to patients, mostly the elderly.  ProPublica looked at Medicare’s data and found 70 physicians with outlying prescribing records, including abnormally high prescriptions per day, or high numbers of prescriptions for sedatives, narcotics, and antipsychotics.  The article says that the Center for Medicare Services, or CMS, is not monitoring doctors closely enough.

Now, I don’t know how many doctors prescribe to patients who have Medicare Part D, but I bet it’s a much larger number than 70.  ProPublica pulled out some of the most egregious examples to illustrate their point.  There are doubtless some charlatan physicians out there and some unscrupulous ones, but not many.  Let’s forget the doctors who prescribe for cash or to game the system.  Everybody else might be trying to do the right thing in a misguided way.

For example, ProPublica cites one physician who prescribes too many antipsychotics for demented patients.  The thing about dementia is that it causes people to do things that are dangerous to themselves.  In some cases the drugs can help decrease the disordered thinking that leads to dangerous behavior.  The best thing for a demented patient is to have someone who cares about them watching them or very near them all the time, to prevent harm.  This doesn’t happen of course.  A bunch of demented people get put in a big ward with one or two nurses.  If no one can watch them, the solution is to medicate them.  A nursing home medical director may be doing the best he can in a bad situation.

Other doctors prescribe too many narcotics.  There are multiple reasons for this, some having to do with patient population or specialty, others having to do with path of least resistance, yet others having to do with patient and family demands.  And yes,  some doctors would rather just prescribe something to get you out of their office than try to deal with what’s really wrong with you.

Physicians prescribe things that aren’t approved by the FDA for specific uses.  For example, Haldol, an antipsychotic, has well-known anti-nausea properties.  I don’t believe it is FDA approved for this use.  Propofol, a powerful sedative, also has anti-nausea properties not approved by the FDA.  Decadron, a steroid, also has anti-nausea properties.   Sometimes it’s voodoo, sometimes it’s placebo, sometimes it might actually work.  When someone is really sick, you might try all of them.  Most of the time the doctor is making an effort to help.

Are there unscrupulous or dangerous physicians out there? Absolutely.  Should those physicians be stopped.  Absolutely.  The problem is that you have to scrutinize everyone all the time to find these 70 guys.  It becomes kind of like homeland security guys at the airport; everybody has to take their shoes off because one guy had a bright idea.  How many terrorists has that system caught?

More regulation is not the answer.  If you make more rules, you burden the honest folks while the dishonest ones will find a way to work around them.  Let’s look at why this is happening.  Do demented people need more supervision?  Do doctors need more time to evaluate pain?  Do medical schools need to teach pharmacology better?  Do residency programs need to evaluate young physicians in their pharma usage?

There will always be bad actors.  Let’s not punish everyone else for their behavior.

Shirie Leng is an anesthesiologist who blogs at medicine for real.

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