Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Pizza or insulin: What does our society value more?

Vipan Nikore, MD
Physician
January 11, 2014
Share
Tweet
Share

Recently, I treated a young patient with diabetes in the hospital. Throughout her young life she had struggled with glucose control, and on this day her struggle left her in a state of diabetic ketoacidosis (DKA). DKA is a life-threatening condition that diabetics often face when their body is  unable to uptake enough glucose, leading to utilization of fat and consequential build up of acidic ketones, which cause blood levels to reach a dangerously acidic state.  DKA has many triggers, such as infection, poor compliance and myocardial infarction to name but a few.

A combination of infection and poor compliance led to her hospitalization. I treated her DKA, but I also invested time trying to understand her barriers to medication compliance. She confessed that her long-acting medicine, insulin glargine, was causing severe burning and stinging at the site of injection.  It is a rare reaction, as glargine is generally very well tolerated.  My solution was to start her on an alternative long-acting medicine, insulin detemir, which she tolerated well in the hospital.  She recovered from her illness, I built a good rapport with her reinforcing the importance of compliance, and discharged her on this new medicine she could tolerate. This could be a new start for her, I thought.

I felt pretty good about myself — for about 3 hours. I soon received a call from the pharmacy explaining that her insulin detemir was not approved. She would need prior authorization. Great, the dreaded prior authorization form, the bane of my (and many other physicians’) existence. Non-standard medicines that are not typically covered on medication plans often require this special authorization.

I immediately called the prior authorization office for approval. Unfortunately I was told that “the prior authorization office was closed on weekends.” Closed! There had to be some way to get my patient her insulin. I spoke to supervisors and made calls after work while in the gym. I simply tried everything but could not find any way to get any emergency override.  I was forced to call the patient and provide an inferior solution to get her through the weekend.

She was approved for prior authorization for her insulin this week, but I am still disturbed by the experience.

This past Thanksgiving, Pizza Hut fired one of its managers, Tony Rohr, for closing his store on Thanksgiving.  (Public pressure caused Pizza Hut to reverse this decision.)  On Thanksgiving, this traditional family holiday, hundreds of stores were open. Yet still, I cannot provide life-saving insulin to a patient in need on holidays or weekends.

Why as a society do we accept such policies? As a physician I’ve had to work on many holidays, and while I’m never excited about being away from family during this time, I understand that it’s part of what we do and what patients need. Why can a company not provide 24/7 hours for critical services? In fact, why do we even require prior authorization? Yes, I understand the health plans need to try to be cost effective and assure that the less expensive solution is provided for the patient with all else being equal, but the concept of prior authorization is another layer of bureaucracy that creates more inefficiency in our broken system.

I know of several creative ways that use technology to provide simple checks to assure cost-effective practices. Why do I need to be on hold for 30 minutes, argue with non-clinicians about my decision, and fax (yes, fax!) my justification to the health plan? Further, patients don’t get their medicine in a timely manner, discharges are often held up in hospitals, and these inefficiencies contribute to driving our healthcare system into bankruptcy.

A 2009 Health Affairs article estimated that prior authorization costs between $23 and $31 billion dollars.  It’s a false barrier that adds little value. Is the insurance benefits manager going to convince me, a board-certified internal medicine physician, that my patient is not going to need insulin detemir? This phony barrier saves the company money if they can withhold some expensive meds from some patients, but it is at the expense of taxpayers and the rest of society. It is akin to a company saving costs by dumping dangerous chemicals in the environment, while people suffer in the process and others are forced to clean it up.

Sadly, I have become somewhat numb to the process and was willing to put up with it to get my patient her medicine.  However, the fact I don’t even have access to this archaic preauthorization process on weekends is beyond unacceptable. I asked the pharmacist how often this happens, and she voiced her frustration, explaining it happens all the time.

My stance is clear: I favor scrapping the idea of prior authorization. But if that’s not going to happen, then companies need to come up with creative solutions to provide 24/7 access (i.e., a temporary three-day override by the pharmacist/physician, an automated system, one on-call person available, hire someone from a different time zone, etc). I (and I’m sure many other doctors) would work closely with the powers that be to help design a reasonably cost-effective solution. It wouldn’t be that hard and wouldn’t cost that much.

And even if it did cause a net loss, guess what? It’s called being accountable. If you want to play in healthcare, you have to understand the system and the critical needs of patients that can’t be left behind.  And if you can’t or don’t want to provide that, then go sell pizza instead.

Vipan Nikore is a hospitalist and president and founder, Urban Future Leaders of the World (uFLOW).

ADVERTISEMENT

Prev

3 health care predictions for the New Year patients should know

January 10, 2014 Kevin 8
…
Next

Through our patients we find ourselves

January 11, 2014 Kevin 4
…

Tagged as: Diabetes, Endocrinology, Medications

Post navigation

< Previous Post
3 health care predictions for the New Year patients should know
Next Post >
Through our patients we find ourselves

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by Vipan Nikore, MD

  • a desk with keyboard and ipad with the kevinmd logo

    Primary care is the missing link in global health

    Vipan Nikore, MD
  • a desk with keyboard and ipad with the kevinmd logo

    The first step to changing the culture in healthcare

    Vipan Nikore, MD
  • a desk with keyboard and ipad with the kevinmd logo

    Work hour restrictions seem painful now, but are a gift

    Vipan Nikore, MD

More in Physician

  • How doctors took back control from hospital executives

    Gene Uzawa Dorio, MD
  • How art and science fueled one woman’s path to medicine

    Amy Avakian, MD
  • In a fractured world, Brian Wilson’s message still heals

    Arthur Lazarus, MD, MBA
  • Why being a physician mom is harder than anyone admits

    Cynthia Chen-Joea, DO, MPH
  • Removing vaccine advisers could jeopardize lives

    J. Leonard Lichtenfeld, MD
  • Why would any physician believe that the practice of medicine will become less abusive for them in the future?

    Curtis G. Graham, MD
  • Most Popular

  • Past Week

    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
    • How the 10th Apple Effect is stealing your joy in medicine

      Neil Baum, MD | Physician
    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
    • Key strategies for smooth EHR transitions in health care

      Sandra Johnson | Tech
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • How dismantling DEI endangers the future of medical care

      Shashank Madhu and Christian Tallo | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How scales of justice saved a doctor-patient relationship

      Neil Baum, MD | Physician
    • The broken health care system doesn’t have to break you

      Jessie Mahoney, MD | Physician
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
  • Recent Posts

    • Inside human trafficking: a guide to recognizing and preventing it [PODCAST]

      The Podcast by KevinMD | Podcast
    • Earwax could hold secrets to cancer, Alzheimer’s, and heart disease

      Sandra Vamos, EdD and Domenic Alaim | Conditions
    • Why male fertility needs to be part of every health conversation

      Hoag Memorial Hospital Presbyterian | Conditions
    • Why health care must adapt to meet the needs of older adults with disabilities

      Lynn A. Schaefer, PhD | Conditions
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
    • Improving patient encounters: time-saving strategies for physicians [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 8 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
    • How the 10th Apple Effect is stealing your joy in medicine

      Neil Baum, MD | Physician
    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
    • Key strategies for smooth EHR transitions in health care

      Sandra Johnson | Tech
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • How dismantling DEI endangers the future of medical care

      Shashank Madhu and Christian Tallo | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How scales of justice saved a doctor-patient relationship

      Neil Baum, MD | Physician
    • The broken health care system doesn’t have to break you

      Jessie Mahoney, MD | Physician
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
  • Recent Posts

    • Inside human trafficking: a guide to recognizing and preventing it [PODCAST]

      The Podcast by KevinMD | Podcast
    • Earwax could hold secrets to cancer, Alzheimer’s, and heart disease

      Sandra Vamos, EdD and Domenic Alaim | Conditions
    • Why male fertility needs to be part of every health conversation

      Hoag Memorial Hospital Presbyterian | Conditions
    • Why health care must adapt to meet the needs of older adults with disabilities

      Lynn A. Schaefer, PhD | Conditions
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
    • Improving patient encounters: time-saving strategies for physicians [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Pizza or insulin: What does our society value more?
8 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...