Fear and loathing in American medicine

By Justin Coby - Guest Columnist

Through the years, angst and ego has cultivated a culture in the practice of medicine that created siloed work environments and logistical nightmares for patients. We in the healthcare industry are quick to call attention to patient non-adherence with handling their health, however, we rarely offer up the fact that the root of the issue might be the patient’s doctor, nurse, pharmacist, etc. are not collaborating well. Perhaps non-compliance has more to do with the provider than the patient.

In 2017, we collected data here at Health Partners Free Clinic in order to study non-adherence (a lack of initiation or continuation of care that a provider has recommended) in our patient population. Among many findings that our 26-question survey produced, we were surprised to find that there was better adherence from our uninsured patients that received all their care at one time versus those under-insured patients that unfortunately didn’t qualify for services beyond seeing a PCP (primary care provider) here at the clinic. This second patient scenario would be seen by the PCP but have their scripts and lab work sent out to places covered by their insurance. The first patient scenario received their care in a vertically-integrated fashion where they were seen by a provider, were given access to medication and pharmacist intervention, and had blood work done all at the same time and place.

Naturally, far and away, the first patient scenario where all practices of medicine available at the clinic (primary care provider, pharmacy, nursing, and phlebotomy) were vertically-integrated and delivered at the same visit produced better adherence. This is what we call a “well duh” observation in the scientific world, however we still struggle to “get it” in the medical models. I would say, primarily, this is due to lack of willingness/ability to collaborate and inefficient reimbursement practices.

Speaking to the willingness/ability for providers from multiple practices to collaborate, I feel that there might not be enough intra-disciplinary exposure during the education and training processes. We at Health Partners try to expose students to our provider team that collaborates as much as we can to improve outcomes for a patient, however we get these students for a very limited time and often at the end of their schooling. To add to this, higher education in the differing provider fields are often a source of silo from other professions. Of course, provider associations can also add to the bad blood with pushes for more independence between mid-level practitioners, whether for the better or the worse.

The lack of efficient collaboration has also been born out of long-developed reimbursement models that Big Insurance can squarely be called to account for. From prior authorizations to medication therapy management, healthcare insurance companies have become the puppet master manipulating the strings that tie practitioners together. No longer is it “doctor knows best,” now we bow down to the actuarial tables. Clearly, we are throwing Big Insurance under the bus here, but we as the providers also ask for the reimbursement that they supply. If you want to get paid by the insurance company, then you will play ball.

What does this lack of collaboration look like on the street level? Have you ever gone into your pharmacy of choice for a refill only to find that you are out of refills? The pharmacy offers to contact the doctor’s office on your behalf and does indeed send a request for a refill. The doctor receives the request and notices that the patient in question needs to be seen in the office to assess the prescribed therapy prior to more refills. The doctor rejects the refill with a message to the pharmacy that the patient must be seen prior to anymore refill authorizations. The doctor assumes the pharmacy will relay this information to the patient and the pharmacy assumes the vice-versa. The patient is never called and returns days later to the pharmacy irate and without medicine. The pharmacy blames the office and the office blames the pharmacy and the patient goes without care. Fear, loathing, angst, and ego.

That was just one minor example of how this inefficiency can rear its ugly head, but many more exist even without bad relations. Sometimes these cracks occur purely from a communication breakdown or the insurance pitfalls mentioned above.

I can say, though, that even outside of the clinic’s walls we do see an emphasis on increased collaboration in our local community. We have been able to build a network of like-minded referral sources for access to services for the uninsured. The Clinic also collaborates well in direct communication with local hospital systems. One innovative example of this is our shared social services program with Upper Valley Medical Center where funding is made available to cover the cost of our social worker interacting directly with uninsured patients while still on the UVMC campus in order to improve continuity of care.

The future of American medicine depends on collaboration of providers and innovative practice models where all disciplines can be present for the needs of the patient at one appointment. We are working towards these models as a community, but it has been long overdue.


By Justin Coby

Guest Columnist

Justin Coby, PharmD, has been affiliated with Health Partners Free Clinic as a volunteer pharmacist since 2007, and was appointed executive director in 2012.

Justin Coby, PharmD, has been affiliated with Health Partners Free Clinic as a volunteer pharmacist since 2007, and was appointed executive director in 2012.