Here’s how a glucometer turned this doctor against Medicaid for all

In a recent Vox interview, Senator Brian Schatz (D-Hawaii) announced his plans to allow individuals without insurance to buy Medicaid coverage. As a family doctor caring for patients on Medicaid in Senator Schatz’s home state, I cannot support such a plan.

Medicare continues to be run by the federal government. In contrast, Medicaid programs are run by states. The trend in recent decades is for states to contract out Medicaid to private insurance corporations. Before 1994, Hawaii’s Medicaid was administered by HMSA, Hawaii’s Blue Cross/Blue Shield. During the Clinton era, the buzzword was “managed competition” among insurance corporations, which would compete on price. In 1994, the State of Hawaii devolved to managed-care Medicaid and started contracting with multiple corporations. In 2009, managed-care Medicaid was extended to the aged, blind and disabled.

Medicaid reimburses at lower rates than Medicare or private insurance, a problem Senator Schatz proposes to fix. However, low reimbursement is just one reason why private and group practices accept few Medicaid patients. Another reason is the administrative barriers put up by insurance companies as well as the headache of dealing with multiple companies. Thus, Medicaid patients must choose from restricted networks of providers. Many are seen by safety net providers such as federally qualified health centers or training clinics.

Different formularies and reporting requirements complicate the practice of medicine to Kafkaesque levels. The helplessness induced by this nightmarish bureaucracy is a major contributor to physician burnout. I want to give just one example by outlining how to prescribe a glucometer.

I first go to the billing section of the patient’s EHR to identify the insurer. Patients on Medicaid in Hawaii must enroll with one of the following: HMSA, AlohaCare, Ohana (WellCare), United Healthcare and Kaiser. I then go to The Prescribing Guide to identify which brand of glucometer (Freestyle, OneTouch, AccuChek) I can prescribe. Each insurer contracts with a specific manufacturer, and the preferred brand can change every six months. If you enter the wrong brand, the pharmacy will tell you to obtain prior authorization.

Next, I have to identify the ICD-10 diabetes code of the highest complexity. Does she have nephropathy, neuropathy, ophthalmopathy? I search for the creatinine/GFR. What did the optometrist say? Am I going to prescribe insulin? Insulin justifies asking for more test strips. All of this – the number of measurements per day, the ICD-10 code, and whether or not the patient is on insulin has to be on the prescription.

“All the world’s a stage, And all the men and women merely players” -Shakespeare

Who wrote this play? Alfred Jarry? Samuel Beckett? No, this theater of the absurd was composed by the business administration types that have piled onto the health care system over the past decades to bring us corporate efficiency. Insurance companies limit their costs by imposing roadblocks. We throw up our hands and decide, no, it’s not worth the hassle to prescribe a GLP1 agonist or an SGLT2 inhibitor – because the prior authorization form requires the dates that the patient took every other diabetes medication ever prescribed.

Our employers have hired their own armies of coders and billers in an arms race with the insurers. These coders find our documentation lacks the elements necessary to maximize return. So now we are instructed to write addenda to chart notes from months ago. The billers shake their heads sadly and say to themselves, “Dr. Yamada, you are such a loser.”

The new interns started in July. When they were medical students, I taught them pathophysiology, clinical epidemiology, patient-centered approaches or social determinants of health. All of that goes out the window. Now I teach them how to enter E&M codes and how to prescribe a glucometer. They are dumbfounded by how Byzantine our health system is. They realize that I am no longer teaching medicine. There is no time for that now. There is only throughput.

“Welcome to the desert of the real,” I say. “Get used to it.”

The MBAs who manage us now say, “We’re not going to pay you for throughput anymore. We’re going to pay for performance, for quality. We don’t care how many times you see the patient. We only care about their A1cs.”

OK, then, tell me what’s the point of telling the homeless patient to eat more fresh vegetables? What use is the A1c when the patient has cancer? What does the domestic violence survivor care about her A1c? To measure physician quality with A1cs is like the drunkard searching for his keys under the streetlight because that’s where the light is. The A1c is easily measured. Other aspects of medical care not so.

The corporate mindset has so thoroughly taken over American medicine that we can hardly see the forest for the trees. EHRs, designed for reimbursement, define the patient encounter – such that physicians look only at their screens, search through drop-down menus, and click in and out of multiple windows. I can’t afford to make eye contact with my patients. Lunchtime is for catching up with charting or returning phone calls. Medication refills? Lab or X-ray results? Planning for tomorrow’s patients? Evenings or weekends by remote access.

Though Senator Schatz’s proposes to make Medicaid into something like a public option, it would likely leave intact Medicaid managed care – with its restricted networks and administrative hassles. As a practicing physician, I want corporate profits and the layers of bureaucrats out of medicine. The American physician is in a predicament like that of Josef K in Kafka’s The Trial. The rules are obscure and constantly changing. We are never told what crime we committed to justify our being treated this way. The practice of medicine needs to be rationalized so that we health workers can focus on the medicine again. Medicare for all is what we need. Not all the problems of American medicine will be fixed by Medicare for all — but we need a way out of this Kafka novel.

Seiji Yamada is a family physician.

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