by Seth J. Baum, MD

I’ve written extensively about the mounting burden borne by doctors and patients. Looking beyond the escalating regulatory time-drains beleaguering doctors throughout the nation we see that simply prescribing medications for our patients has become a tribulation. Why this is so and what ramifications ensue, deserves exploration. Thus I have written this commentary, with the hope that our beaten horse continues to have a pulse. I’m sure this will not be the last of such discussions; the topic is too important to be discarded.

Doctors have been writing prescriptions since the advent of medical practice. Maimonides, Hippocrates, Witchdoctors, and all other forms of medical practitioner have taken pen to paper (or chisel to stone) in an effort to help patients. Sometimes our prescriptions work; other times we are not so fortunate. Still, we trudge onward, always trying to better our skills and our recommendations. Offering advice is a fundamental aspect of practicing medicine, and such guidance often comes in the form of a prescription. Until recently this custom remained unchallenged. So why the sudden change?

The US is enduring tough economic times and healthcare represents a large part of our economic burden. Consequently the medical system is being assessed from all angles. In some ways it is even being deconstructed to alleviate portions of this problem. Unfortunately among all the sectors of healthcare, physicians and other HCPs have the worst political representation. We are a poorly organized group often likened to cats that cannot be herded. And so we are the weakened fawn, easy prey for the hunting lion. Hospitals, insurance providers, and businessmen who own huge medical groups run fast, free and unencumbered while we are taken down with but a muffled sound. The unrecognized consequence however, is that when we lose, our patients do so as well. Let’s examine cholesterol-lowering drugs as a contemporaneous example of this phenomenon.

Our cholesterol-lowering armamentarium boasts seven statins, a cholesterol absorption inhibitor, bile acid sequestrants, niacin, fibrates, omega-3 fatty acids, and now PCSK9 inhibitors. One would think that with so many tools at our disposal we could win the battle against cholesterol mediated heart and brain disease. Not so. Barrier upon barrier has been constructed to preclude our free use of most of these medicines. The architects of such barriers assert that doctors need them, lest they unwisely or improperly prescribe medicines. They also claim that absent specific forms of data, doctors should no longer be permitted to prescribe medicines on the basis of our understanding of disease processes and our detailed discussions with our partners, the patients. Both declarations are apocryphal. Yes, doctors do make mistakes, but after 10+ years of post-college training, and oftentimes decades of clinical experience, who better is equipped to render medication recommendations? As for prescribing “off label”, this has been commonplace for decades. Many of our prescriptions extend beyond label indications. Physicians do this solely to help our patients. What everyone needs to understand is that doctors and other healthcare practitioners have no financial motivation to prescribe these treatments. Our only objective is to do the best for our patients. (Interestingly under the current healthcare system, doctors often do have a financial incentive to withhold medications and other treatments from their patients. But that’s entirely another story.)

An anecdote might be useful here. The late Stanley Preiser, one of the top 100 attorneys of the last century and a very dear friend, often spoke of a case he won against an insurance company who had a formal policy to discard 50% of insurance claims. Stanley previously spoke of this case with intense disdain and skepticism, barking “Can you imagine randomly throwing every other claim in the garbage!” The concept was that a high enough proportion of these missing claims would never be resubmitted. The insurance company saved millions. The question therefore arises whether we are now experiencing similar obstacles being employed under the pretext of patient-friendly (and anti-doctor) propaganda. The modern day barriers are similar to the old-style garbage dump technique in that many practitioners will eventually cry uncle. They will simply give up. Then there are the economic analyses. They determine the “cost-effectiveness” of medications. But they are just models built upon a limited number of assumptions. Also, they possess a vital (and to me incalculable) ingredient, the valuation of a single life. If a medication costs more than the calculated value of life, it is declared worthless. This brand of thinking establishes a dangerous precedent, one that must be exposed and eradicated. Again, the losers are the patients. To reiterate, please understand that physicians have absolutely NO motivation to prescribe cholesterol-lowering medicines other than the profound desire to help their patients.

Though I’ve not provided a solution for our medical economic crisis, my goal was to expose a different but equally dangerous issue. Only through candor and awareness can we hope to correct our crisis. Hopefully this brief commentary will stimulate further discussion; perhaps even serious investigations into the tactics being utilized to quell doctors’ capacity to help their patients. Hopefully the horse really does still have a pulse.