Your Voice: JAMA study doesn't give doctors enough credit

any years ago, I wrote a letter to the editor of JAMA following their article condemning doctors for accepting gifts, dinners, etc. I am in complete agreement with Dr. Ellis (“JAMA study a slap in the face to physicians,” August 10, 2016)) that it is an insult to the integrity of physicians that others believe our prescribing habits are influenced by a donut.

In my letter, I pointed out that they were complaining in a journal that physicians were receiving for free courtesy of the pharmaceutical companies. Should we therefore assume that everything in JAMA is biased because it is a pharmaceutical gift?

The same could be said of Medical Economics since we receive it at no cost. 

I would ask you if I should question the veracity of your articles because of pharmaceutical subsidies. I practiced as a solo doctor for many years and attended numerous pharmaceutical dinners. Most of them were very informative and given by very reputable speakers.

I also think I was smart enough to tell the wheat from the chaff.  What is interesting is when I joined a large group whose policy was that physicians should not accept samples or attend pharmaceutical sponsored dinners, I found that the bright, young doctors I worked with didn’t have a clue about the new medicines that were available.  

The only response I ever received from my patients when I handed them some free samples was a thanks. I realize perception is important, but the only folks who seem to have a problem with this is the government and our own industry-not the patients. 

Isn’t it time to give physicians some credit for having a brain and allow each physician to decide for him/herself as to what type of relationship they want to have with the pharmaceutical industry?

Steven Howard MD

Belmont, California 

Prescribing decisions dictated by payers

Dr. Kohil wrote an interesting article about doctors needing to be aware of medication costs when making prescribing decisions (The last word, August 10, 2016) but her essay ignored a few realities of practice today.

Prescribing decisions are dictated by insurance company formularies, not doctor or patient preference. The patient might want Eliquis and you might agree that it is the best option, but if the insurance company only covers warfarin, that’s what the patient is going to get. 

Perhaps you have the staff and time to appeal a denial and obtain prior authorization for the preferred drug, but even then you may find that the copay is cost prohibitive for your patient.

It is impossible for us to know what any particular drug costs since the cost and coverage can vary dramatically from plan to plan. Also, the cost and coverage often changes on January 1. 

I can’t tell you how many times I had a patient on Drug A and on January 1 had to change it to Drug B. Then a year later, I had to change it back to Drug A, or perhaps to Drug C.

We, as doctors, don’t get to decide what is best for our patients, and the patient certainly gets no say in that decision.

Steven Gitler, DO

Camden, New Jersey

PQRS is insulting to the integrity of physicians 

I am very upset about losing my appeal with the CMS Physician Quality Reporting System (PQRS).   

Because of an unfair and arbitrary process, my practice will lose thousands of dollars this year.  We made a perfectly valid appeal and were harshly denied: “This decision is final.”  

I run a solo practice of internal medicine in a small town.  My wife, an RN, is my office manager and she worked diligently in 2014 to fulfill the “quality” inputs. Three measures were performed, as we were supposed to do.  Two, we did perfectly well and passed (hundreds of patient encounters and data entries).  The third was denied because the CMS “denominator” was misunderstood and/or inappropriately determined.  

For example, it included patients who died, lived elsewhere, or changed to a new doctor, so it was impossible to reconcile their medications after a hospitalization.  Also, the wording of the policy is confusing.   

So, CMS said we were five patients short on Measure 46 and they did not show any understanding or sympathy on our appeal – the space for which on the online form was very limited.

We then get NO credit, only penalization, for all our many hours of efforts over the whole year.  We did 99% right, spending a ton of resources on this “quality” project, and get worse than zero for all our efforts!  This is unfair and insulting to our integrity and professionalism.

This sort of governmental arbitrariness embitters well-meaning physicians trying to make a living, particularly those of us without the resources of big groups.

Physicians should be spared this major frustration.  Practicing medicine is difficult enough. 

J. Gary Grant, MD

Pacific Grove, California

Agree on tort reform’s role in solving defensive medicine

In “Tort reform necessary to solve defensive medicine” (Your voice, June 25, 2016) Calvin S. Ennis, MD, was right to express his frustration with the way our tort system deals with medical malpractice.

Making plaintiffs’ attorneys (if they lose their case) pay the defense attorneys’ fees as he suggests would probably go a long way to cutting down on frivolous law suits.

But special health courts presided over by judges with special training in medical malpractice should also be considered as a solution. They have the potential to resolve cases quickly, and cut down on administrative costs and excessive payouts.

Both patients and doctors would be treated in a reasonable way, reducing the fierce hostility and adversarialism that now prevail. And defensive medicine, though it would not disappear, entirely would be lessened significantly.

Edward Volpintesta MD

Bethel, Connecticut

CMS saddling primary care with too many burdens

I read with interest the various report cards on the different challenges medicine is currently facing. 

As a general internal medicine physician, the primary care incentive pay article was particularly interesting. I think it is important to understand that this bonus was simply a lifeline to primary care practices that had heavy exposure to Medicare patients.

In a busy and mature internal medicine practice, Medicare is frequently well over 50% of the practice. In my case, the bonus amounted to an additional one-half month of revenue. This is certainly a significant amount of money for any practice. I don’t think there is any real expectation from CMS that this incentive pay would change behaviors. It was simply an attempt to help maintain financial stability for these practices.

Unfortunately, our leaders in organized medicine were focused solely on getting rid of the SGR.

During their rush to make a deal on this, they basically gave away too much. They have saddled primary care with additional burdens under MIPS. Eventually, specialists will have some of these burdens as well. 

However, primary care will remain the most heavily burdened with these programs. In addition to having more bureaucratic burdens, we gave up the money from the primary care incentive program. I don’t think there was anything similar that was given up by the specialist community.

John S Matlock, MD

San Antonio, Texas