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Heart Month: Looking Back on 2015 and Forward into 2016

woman jogging
by Seth J. Baum, MD

February is National Heart Month – a time of hope, jubilation and pride. Each year many of us write blogs or articles espousing the sentiments of optimism and accomplishment. We discuss all that has occurred and all that is promised to be. This year I must take a different tact. This year another aspect of healthcare deserves to share center stage. A Leviathan has emerged that threatens to strip us of the accomplishments so fiercely earned. I speak of a Kraken whose tentacles are pervasive and penetrating. This beast is none other than our Insurance Providers. To understand such an allegation, let’s examine a typical cardiovascular practice.

Great advances were made in 2015 – two new heart failure drugs, a cardiovascular disease-reducing diabetes medication, and the revolutionary lipid lowering drugs, the PCSK9 inhibitors all became available to better treat our patients’ ailments. Doctors were overjoyed with this panoply of novel and potentially life-saving additions to our armamentarium. And so we began to prescribe. That is what doctors do after all, identify and utilize what they consider to be beneficial therapies for their patients. No financial remuneration is gained; it is solely the satisfaction of helping our patients that fuels physicians’ interest in novel treatments.

Many of us have spent decades endeavoring to understand the nuances of diseases and their remedies. So when we prescribed these cures and found our prescriptions repeatedly denied by clerks, nurses, and less well-informed physicians, shock and dismay engulfed us. Doctors have universally shared this experience across the nation. Everywhere insurance providers are demanding that we alter our treatments to suit their arbitrary and monetarily motivated formularies. Their requirements not only place enormous burdens upon physicians and their staff, but they also necessitate numerous prolonged medication trials that patients must endure before they can receive the optimal care their physicians have prescribed. Does this make sense? Medical education is demanding, long (10+ years after college), and extraordinarily complex. Additionally, no one can know your medical condition better than your physician. Should someone who has never seen you, never had the opportunity to speak with you or lay his or her hands on you, someone who lacks the skillset of your doctor, and an individual with an irrefutably vested financial interest in denying the prescriptions of your doctor be in a position to countermand your doctor’s orders? Clearly the answer is no, yet equally clearly this is precisely what takes place every day in every doctor’s office in America.

Prior discussions of “death panels” drew charges of paranoia, but are we now experiencing a subtler form of what we feared? To many of us in the know, this appears to be the case. So what are we to do? On one hand medical science is advancing at a spectacular rate. On the other, the successes of science are being withheld from the very patients for whom they were designed to help. The only solution as I see it is for patients and physicians to unite and demand complete transparency from the insurers. We must hold the insurance providers and their physician emissaries accountable for their actions. When they influence your care and countermand the orders of your personal physician, they are in reality acting as your doctor. Should their management fail and you suffer an adverse outcome, they need to have their feet held to the fire. They are culpable and must be recognized as such. So this Heart Month while we celebrate our wonderful scientific successes, let’s also band together to ensure that we can reap the rewards of the efforts of dedicated and forward thinking researchers. After all, medical advances as amazing as they are have no value if they are withheld from people who need them.

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