jmj11 Posted October 3, 2014 Share Posted October 3, 2014 All of us old - timers remember the days when radiology / labs refused to do our tests. Where pharmacists refused to fill our Rx (even though we had the legal right to write them) and specialists refused to see our referrals. It is MUCH better now, but I was thinking about this yesterday, that patients still have to carry the pain of prejudices against us. Case 1: Headache patient came to see me for a new onset of localized headache. A long story but I will summarize. She had a shunt X 15 years. Her head pain is 100% from the shunt (extremely tender along the shunt in her left parietal, plus it is swollen and inflamed). I suspect that is is a local, mechanical problem (or possibly infection) not a central shunt failure. But she describes her pain as 8-9/10 and can't be ignored. I made a referral to neurosurgery to look at it. They belong to a very large medical empire. They required her to see the neurologist in their empire first. The neurologist spent 10 minutes with her as all providers in that empire are required to do. The neurologist never touched the patient, never did an exam but ordered an MRI. The ventricles look fine so she dx the patient as not having "shunt failure" but has "stress headaches" (no such thing) and (over the phone) put the 75 year old partially demented patient on Topmax. Because the patient has medicare, we have not been able to find any other neurosurgery practice to look at her. Case 2: The requirement for coverage for Botox for migraine treatment (per most insurance companies) is >14 days per month of migraine and failure of 3 preventives from at least two different classes. Meet Brenda. She is a 44 year old lady who has suffered from migraine her entire life, which reached a level of being daily about 8 years ago. The average pain level is 7-8/10 and she can barely function, but never misses work. She has seen four neurologists and one other headache clinic. She really didn't want to do Botox so we put it off as last resort. I submitted my 4 page prior auth letter and chart notes. The patient has migraine 30 days out of 30 and has failed a total of 18 preventative medications from five classes (at least). She has had multiple other procedures (nerve blocks and etc.) I thought getting Botox for her would be a slam dunk. Meet Ruth, the insurance RN. She called my office manager for "clarification" yesterday. In summary she was appalled that a PA was doing Botox and asked, more like lectured, "Does his supervising physician know he is doing Botox?" She went on to try to say that would be illegal and yada yada yada. There is no question she would have approved this for an NP doing the procedure. She had already discussed this with the physician at the insurance company and he agreed that they will not pay for the procedure if I do it because PAs are not qualified (I've been doing Botox for migraine for 12 years). So here is two examples of patients being punished because of anti-PA bigotry (or just plan stupidity). Link to comment Share on other sites More sharing options...
SoCal_PA Posted October 3, 2014 Share Posted October 3, 2014 How recently has something like that happened to you? Link to comment Share on other sites More sharing options...
Marinejiujitsu Posted October 3, 2014 Share Posted October 3, 2014 I would have called Ruth and asked if she was new and knew what a PA was. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted October 3, 2014 Administrator Share Posted October 3, 2014 To whom can you complain? MQAC? Insurance commissioner? If by law we can sign anything our SPs can (as Washington State PAs) does that not implicitly require that other medical professionals accept our signed orders as if signed by an MD? Link to comment Share on other sites More sharing options...
jdenning Posted October 4, 2014 Share Posted October 4, 2014 Case #1 is really about neurosurgery ethics, isn't it? Doesn't the neurosurgeon who put the shunt in 15 years ago carry some degree of responsibility for this patient ongoing? Why is it so hard years later to go back to the surgeon that put the thing in? Shunts are mechanical things and their parts can fail and immune systems can reject the tubing et cetera. Doesn't the guy who put the thing in owe this patient something??? We have encountered this with a number of patients now...neurosurgeon won't see them back because their insurance changed etc. One patient who had intractable headaches and WAS in shunt failure and it took multiple episodes of me and SP pleading to get not just a shunt series done but trying to find a neurosurgery group willing to push the isotope... And putting a 75 year old with cognitive problems on Topamax is just plan irresponsible. There are a multitude of choices but at least start with an exam. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 4, 2014 Moderator Share Posted October 4, 2014 it used to be that PAs in my state couldn't write for sch 2 narcs in the er for anything so pts suffered....imagine shoulder dislocation reductions with stadol and toradol...not ideal.... Link to comment Share on other sites More sharing options...
Guest Paula Posted October 4, 2014 Share Posted October 4, 2014 I think it's time to publish these incidents in the local paper or start a website detailing the insurance companies who deny care. Or would PAs just be discriminated against again and the articles would be written from a point of ignorance and stupidity? The nurse at insurance company is truly ignorant and so is the physician. AAPA won't touch these type of issues with a ten foot pole. I fear government won't get involved either as it looks at bottom dollar and won't make a physician do the right thing. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted October 4, 2014 Moderator Share Posted October 4, 2014 I think it's time to publish these incidents in the local paper or start a website detailing the insurance companies who deny care. Or would PAs just be discriminated against again and the articles would be written from a point of ignorance and stupidity? The nurse at insurance company is truly ignorant and so is the physician. AAPA won't touch these type of issues with a ten foot pole. I fear government won't get involved either as it looks at bottom dollar and won't make a physician do the right thing. A website/centralized forum accessible to the public with these types of patient-centered stories is not a bad idea, if done the right way... Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 4, 2014 Moderator Share Posted October 4, 2014 every time I get a VNA referral - jumping through hoops to get them in.... finally after 2 years of business most the local agencies know me and will work with me - one still is a PIA and will refuse to work with me Link to comment Share on other sites More sharing options...
Guest Paula Posted October 5, 2014 Share Posted October 5, 2014 PIA? Ignorant here.....but you probably can't print it!!!! I know what POS is tho. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted October 5, 2014 Share Posted October 5, 2014 How about PITA instead of PIA (gluteal region). Link to comment Share on other sites More sharing options...
Guest Paula Posted October 5, 2014 Share Posted October 5, 2014 I got it!!! Link to comment Share on other sites More sharing options...
JFarnsworth Posted October 5, 2014 Share Posted October 5, 2014 In response to the OP, I once worked in an ER where PAs were not allowed to contact specialists for consults on our patients. We had to go to our SP, present the case, tell them why we wanted the consult, and then get both docs on the phone, as long as your SP agreed that a consult was necessary. I ignored that little rule and would call specialists to ask if they thought a consult was appropriate, or if not, what I could do for the patient. That put the onus on them because for sure I documented that I called them and what they said. Most of the time the docs were nice, a couple of times they were not. I didn't care. In the same ER, the rad techs refused to come in after hours if a PA wanted a test (CT scan, MRI, US, etc). I had a kid with a suspected appendicitis, and the rad tech refused to come in to give this kid a CT. So I got their name, documented what happened, and lo and behold, the kid came back the next day with.... appendicitis! I was called up for a QA and once they found out what happened, the Rad techs had to come in if a PA wanted a test done. So, yes, the patient suffered from pain for 24 hours because they had the misfortune of seeing me. But at least it changed the policy of the ER. Hate to say it, but once you call people on this kind of behavior, name them in the patient's chart, document what happened, the best recourse might be to inform the patient why something is denied and let them take it from there. The hint of legal action sometimes spurs people to change their opinions drastically. Link to comment Share on other sites More sharing options...
Guest Paula Posted October 5, 2014 Share Posted October 5, 2014 When I worked ER locums there were a few hospitalist docs that did not want to admit some patients. They would try to pawn them off to a larger center and not do the consult for admittance. I had one patient in particular who had bilateral DVTs, had stopped taking her coumadin and also had a Greenfield (sp?) filter already in place. Looked like she had cellulitis on one of the legs, too. She was clotted from calf to groin bilaterally and I called the hospitalist. He said "Are you sure?" "Just send them to the mother ship". I said, no, this can be handled here and I need the consult. I had already ordered Lovenox. He said he wouldn't come down to see the patient and I would have to get her ready for transport. I told him that I was taking his advice and would document it clearly that I had a phone consult with him and that he refused to come and evaluate the patient. He arrived to the patient room in two shakes of a lambs tail. He admitted her. Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 6, 2014 Moderator Share Posted October 6, 2014 When I worked ER locums there were a few hospitalist docs that did not want to admit some patients. They would try to pawn them off to a larger center and not do the consult for admittance. I had one patient in particular who had bilateral DVTs, had stopped taking her coumadin and also had a Greenfield (sp?) filter already in place. Looked like she had cellulitis on one of the legs, too. She was clotted from calf to groin bilaterally and I called the hospitalist. He said "Are you sure?" "Just send them to the mother ship". I said, no, this can be handled here and I need the consult. I had already ordered Lovenox. He said he wouldn't come down to see the patient and I would have to get her ready for transport. I told him that I was taking his advice and would document it clearly that I had a phone consult with him and that he refused to come and evaluate the patient. He arrived to the patient room in two shakes of a lambs tail. He admitted her. on that same note...... at a past ER job the hospitalists were really tough to deal with, would not want to talk to the "the PA" and then would refuse to come see the patient saying admission was not needed. I was told by my attending (one of the few good things he ever told me - he was pretty useless and the only reason he told me to do this was so that he would not have to get involved) to simply tell the hospitalist that I had written the admission order and if they wanted to come see the patient and write a DC order they could..... They were much more responsive after that..... and I had to remind them a few times as well...... Link to comment Share on other sites More sharing options...
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