Medical care in the United States is broken. The pandemic contributed, but we were well along this misdirected journey. There is a pathological push/pull between financial pressures applied by payors and health care systems to decrease costs, thereby generating profits versus the desire of providers to deliver outstanding care to patients. This is ingrained into our system as it is designed. The dynamic is further muddled by our unique medicolegal climate. No other example serves to better illustrate this untenable situation than how I am forced to manage acute postoperative pain for my reconstructed patients.
The opioid crisis is well known. Surgeons now possess significant mindfulness when prescribing postoperative pain medications for acute but limited pain. Physicians are appropriately bombarded by their societies, state boards, and patients regarding the need to decrease opioid prescribing. Continuing medical education is abundant regarding this pressing need. So far, so good. The system was slow to react, but the leviathan is moving in the correct direction. The significant role played by the private pharmaceutical industry in sparking this epidemic is also crystalizing before us. Appropriate changes are making their way into health care policy.
When an influential surgeon now prescribes a non-narcotic alternative, they may feel appropriately pleased that the “right thing” is being accomplished. High-five, kudos! Layers of medical bureaucracy are reviewing best practices and counseling surgeons on how to better manage postoperative pain. Hard stops are written into electronic medical records to facilitate better prescribing habits.
Pain management in the acute postoperative setting is a hot topic, and there have been significant improvements in how surgeons manage this vexing issue. There is a growing push to use nerve blocks and regional anesthesia to manage pain better.
Sometimes, I need to order appropriate and effective medications in the post-anesthesia care unit (PACU), but I am called by the hospital pharmacy and informed that it is not permitted due to expense. But when pain is inadequately controlled, and patients are asked to soldier through it, surgeons become fearful of getting a bad online review if they do not satisfy the patient’s requests. Too many poor reviews can lead to lost patient volume or even loss of salary depending upon how an employer structures a surgeon’s compensation package. Some aspects of this problem are uniquely American in how our health care system operates and how patients’ expectations are wired. This is a design flaw.
Nevertheless, I see the next barrier in this struggle but can do nothing. The COX-2 inhibitors are a class of selective nonsteroidal anti-inflammatory drug (NSAID) that are effective in pain relief without narcotic addictive profiles. One of these drugs (Vioxx) was voluntarily taken off the market in 2004 by the manufacturer due to an increased risk of heart attack or stroke. Another related drug (Bextra) quickly followed suit one year later for similar reasons. However, Celebrex is the last drug from this family that remains available. Multiple studies confirm its safety, but there is a “black box” warning with its use. Whom do I trust? Many of my continuing medical education hours are consumed in lectures about prescribing this drug as an appropriate alternative over narcotics. I do so. I have the risk-benefit discussion with patients, but I am already tripping over the next hurdle.
When I prescribe even just one or two of these pills to help appropriate patients manage discomfort while they try to sleep through the night, I am inundated with requests from payers for required authorization. The amount of paperwork asked of me by insurance to simply manage two pills of this drug does not justify the time required to shepherd the request. When I ask insurance companies if they require this onerous authorization to mitigate expenses or review indications for usage, I am not given a response. If I prescribe a narcotic instead, I subsequently risk a pharmacist calling my office to challenge the prescription despite low volume dispensing or even could face the wrath of family members.
I purposely write paper prescriptions (not electronic) so that patients can go to whichever pharmacy is open or offers the better price, rather than push the prescription electronically, forcing a patient somewhere. Freedom of choice is being eliminated. I feel that I navigate these waters alone.
In the United States, so much of what our society demands is federally regulated. I am not a Constitutional attorney, but critical aspects of our society seem to be regulated at the federal, not state, level. The aviation industry, although currently having major problems in customer satisfaction, nevertheless remains extraordinarily safe. The airline industry is successfully regulated by federal agencies. The stock market in all its complexity, answers to federal rules much more so than state. The Army, required for our national protection, is a federal organization despite states having their own National Guard units.
Perhaps one can rationalize physicians are local businesses and should be regulated at the state level. Maybe one can propose that physicians are no different than the local barber. But this is no longer working. Although most health insurance companies may offer specific plans in each state, they operate on a national level. Medical centers are rapidly consolidating and adding further complexity as health industries literally take over large swaths of the country crossing state lines. A physician can see a patient by telehealth but must be careful not to practice in another state. Why are payors and health care systems not regulated more logically?
I realize I am asking for the bureaucratization of our health care system. But what we have now simply is not working. We must have a national discussion. It is time.
Ross Zbar is a plastic surgeon.
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