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It Began with an Email with Stephen Russell, M.D.

It Began with an Email with Stephen Russell, M.D.

LEEDS – Benjamin Franklin said, “Either write something worth reading or do something worth writing.” For Leeds family physician Stephen Russell doing both comes naturally. As an associate professor of internal medicine and pediatrics at the University of Alabama at Birmingham, Dr. Russell is living his research for the characters he writes in his works of fiction, which are centered around Dr. Cooper “Mackie” McKay.

Dr. Russell has written and published three medical thrillers — Blood Money, Command and Control and most recently Control Group — with a fourth in the works. While he admits he has always written in some fashion, it wasn’t until he was in his residency in Cincinnati, OH, when he discovered he had a gift for the craft of storytelling. In fact, he credits the simple act of emailing with his father, who was a practicing cardiologist in Birmingham at the time, with stoking the fire of his love of weaving a good tale.

“I had been given an email address during residency and remember thinking, ‘Well, what am I going to do with that?!’” Dr. Russell laughed. “No one was really using email outside a school setting, but my father had an email address, so I used that as a way to communicate with him a good decade before cell phones were popular. Then I started to write these stories to him in my emails but completely different from an email you might think of today. I was taking all these stories that were really during an intense, emotional and academic time of my life when I was seeing new patients, learning how to treat them, and learning what being a physician was all about. I was retelling these stories of what my patients were going through, and what I was going through learning how to help them. In those emails, I was just beginning to learn how to put things together as a real story. Looking back on it now, those email stories had a character, a narrative arc, an event that happened, and the more I did them the more I realized there were patterns to my writing.”

Not only did Dr. Russell realize his love of the creative process through those early emails to his father, but he also learned just how much he enjoyed how cathartic the writing process itself could be.

Four years later, Dr. Russell began to wonder. “What if…?” Still practicing in Cincinnati, he had met hundreds of patients and had an arsenal of stories and medical scenarios. So, what next?

“I had this idea from things I had done during my residency. ‘What if?’” he wondered. “What if this particular thing happened and something bad happened as a result of it. I decided that instead of continuing to write short stories in the form of emails, I just dove in and decided it would be a fun to write a novel. I had never written a novel before. I had never taken a formal writing class before. I had taken literature classes in college, but nothing to prepare me for writing a novel.”

Dr. Russell is the first to admit writing his novels wasn’t exactly what he thought it would be. While he never expected to turn in his first draft and have it magically be published, he didn’t expect it would take 13 years from draft to publication.

“I had to figure out how to do it for myself by reading about writing great authors and trying to figure out how they wrote in order to do it well. I think if I knew now what I knew then…” he laughed. “What I didn’t expect was that I thought there was going to be this writing part of my life and this physician/professional part of my life. I expected them to be completely separate. But it was interesting to me that these two separate strands I thought were my two parallel lives were actually two parts of the same journey for me.”

As the two parts of his life began to converge, Dr. Russell said he wasn’t expecting the positive impact of being a published author would have on his patients. It turned out to be a pleasant surprise.

“I didn’t expect I’d be talking about writing while I was at work, or having conversations about books with my patients. Then the most amazing thing happened after my book was published. People read it! They would come in for their visits and would want to talk about the book and about writing, which was a great icebreaker. The thing I love most about writing is probably the thing I love the most about being a physician which is communication. My job as a primary care physician is to listen to my patients and interpret their stories and understand what they mean from a health standpoint. How does that story end? How can that story be changed? How can that story be interpreted for a better prognosis?

“That’s also the job of the writer…to create the story if it’s fiction or frame that story if it’s nonfiction and to package it in a way that clearly communicates whatever the writer is trying to tell. I didn’t think about it in those terms when I was writing my first novel, the second or the third, but as I started to be on the receiving end of other people reading my writing, critiquing it and giving comments, I realized that’s part of what I signed up for by entering into the arena as a writer, but it’s also what I signed up for by entering into the arena as a physician, which is just that ability to try and find a way to communicate what I’m doing clearly and try and help my patients communicate what they’re experiencing and feeling in a way that makes sense to them. That whole communication journey is what makes sense to me about why I enjoy writing but also why I enjoy being a primary care physician,” Dr. Russell said.

EDITOR’S NOTE: Dr. Russell has written three medical mysteries, which you can purchase on Amazon: Blood Money, Command and Control, and Control Group. He promises Dr. Cooper “Mackie” McKay will return in the future. In the meantime, he’s working on a young adult novel in which he’s getting plenty of input and primary research from his four children.

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Physicians Call for Prior Authorization Reform

Physicians Call for Prior Authorization Reform

The Medical Association has joined a coalition of physicians’ groups, hospitals, medical groups, pharmacists and other health care organizations to urge health plans, benefit managers and other groups to reform prior authorization requirements imposed on medical tests, procedures, devices and medications. The coalition is responding to what has been deemed unreasonable hurdles for patients seeking care and argue that requiring pre-approval by insurers before certain treatments can delay or interrupt medical services, divert significant resources from patient care and complicate medical decisions.

Given the potential barriers prior authorizations can pose to patient-centered care, the coalition is urging an industry-wide reassessment of these programs to align with a newly created set of 21 principles. Prior authorization programs could be improved by applying the principles’ common-sense concepts grouped in five broad categories:

  • Clinical validity,
  • Continuity of care,
  • Transparency and fairness,
  • Timely access and administrative efficiency, and
  • Alternatives and exemptions.

“Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited health care resources and antagonized patients and physicians alike,” said AMA President Andrew W. Gurman, M.D. “The AMA joins the other coalition organizations in urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs.”

The data entry and administrative tasks associated with prior authorization reduce time available for patients. According to a new AMA survey, every week a medical practice completes an average of 37 prior authorization requirements per physician, which takes a physician and their staff an average of 16 hours, or the equivalent of two business days, to process.

The AMA survey illustrates that physician concerns with the undue burdens of preauthorizing medical care have reached a critical level. Highlights from the AMA survey include:

  • Seventy-five percent of surveyed physicians described prior authorization burdens as high or extremely high.
  • More than a third of surveyed physicians reported having staff who work exclusively on prior authorization.
  • Nearly 60 percent of surveyed physicians reported that their practices wait, on average, at least one business day for prior authorization decisions—and  more than 25 percent of physicians said they wait 3 business days or longer.
  • Nearly 90 percent of surveyed physicians reported that prior authorization sometimes, often, or always delays access to care.

For specialists like Montgomery oncologist Stephen Davidson, M.D., at the Montgomery Cancer Center, issues with PAs can begin when the patient checks in for the first appointment.

“There are days when I have patients who are scheduled to see me as new patients. They are at the front door. They have something that brought them here that has also emotionally disturbed them greatly. If their PA is not in place, they can’t so much as walk down the hall to see me,” Dr. Davidson said. “This happens…constantly.”

Dr. Davidson and his team see an average of 60 patients each day. During that time, he and his treatment team are also securing PAs for patients for imaging and medicine. Rarely are cancer medications generic, making them very expensive, so PAs must be secured for monthly refills, taking even more time away from patient care.

“It has become a tremendous burden,” Dr. Davidson said. “Somewhere along the way the burden of proof shifted from the insurance company to the physician. Traditionally there has been a respect for a physician’s judgment and decision making on behalf of the patient. That’s a very special and sacred relationship. Now, because of a number of factors, primarily economic, we have insurance companies that don’t respect the physician’s authority in the decision-making process.”

Read more about what Dr. Davidson and Lee Carter, M.D., of Autaugaville had to say about PAs in our article from Alabama Medicine magazine, Between Doctors & Physicians: Prior Authorizations.

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Between Doctors & Patients: Prior Authorizations

Between Doctors & Patients: Prior Authorizations

Physicians face various regulatory and administrative hurdles in a day, but few are as frustrating, or as expensive, as prior authorizations, or PAs. Commercial insurance companies, Medicaid, Medicare and other third-party interests use PAs to reduce costs. This leaves physicians and their staff wondering when the practice of medicine became more about the dollars and cents than what makes sense for patients?

“The system is there for a reason, and we understand that,” Lee Carter, M.D., said. Dr. Carter practices family medicine in Autaugaville, a rural community in Autauga County with a population of less than 1,000. “But, it can be very frustrating, not only to the physicians and our staff, but to the patients who have to wait for their medications.

According to a 2012 Kaiser Family Foundation estimate of about 835,000 practicing physicians, 868.4 million hours are spent annually on PAs. A 2011 study by Health Affairs estimated physicians spend an average of $83,000 annually interacting with insurance plans to secure prescribed treatments, procedures or therapies for patients needing prior approvals.

In Dr. Carter’s practice, he and his partner treat a variety of issues in their patients ranging from colds and flu to more chronic conditions like diabetes and ADHD as well as procedures involving MRIs and X-rays. Each physician has a staff member devoted to prescription renewals and obtaining PAs. Still, keeping up with the demands of charting and following the rules for the payers for PAs can be daunting.

“When a patient comes in that you’ve been treating for months or even years, and you know there’s something new out there that will work better for that situation, you want to find what works best for your patient. Most of the time, that medication is going to be a generic, which is covered by most insurance plans because it’s cheaper for them and it’s cheaper for your patient. But, what if that med doesn’t work for your patient? What if your patient is allergic to that med or another med? You have to find a balance. That’s the key,” Dr. Carter said.

For specialists like oncologist Stephen Davidson, M.D., at the Montgomery Cancer Center, issues with PAs can begin when the patient checks in for the first appointment.

“There are days when I have patients who are scheduled to see me as new patients. They are at the front door. They have something that brought them here that has also emotionally disturbed them greatly. If their PA is not in place, they can’t so much as walk down the hall to see me,” Dr. Davidson said. “This happens…constantly.”

Dr. Davidson and his team see an average of 60 patients each day. During that time, he and his treatment team are also securing PAs for patients for imaging and medicine. Rarely are cancer medications generic, making them very expensive, so PAs must be secured for monthly refills, taking even more time away from patient care.

“It has become a tremendous burden,” Dr. Davidson said. “Somewhere along the way the burden of proof shifted from the insurance company to the physician. Traditionally there has been a respect for a physician’s judgment and decision making on behalf of the patient. That’s a very special and sacred relationship. Now, because of a number of factors, primarily economic, we have insurance companies that don’t respect the physician’s authority in the decision-making process.”

According to Dr. Davidson, the burden of proof isn’t specific to oncology. Physicians fighting to get the best treatment regimens for their patients have all experienced the same process with payers in trying to secure prior authorizations, and perhaps the most time consuming and frustrating part of the system is the peer-to-peer conversations in which physicians advocate on behalf of their patients with the payers.

“The problem is that in oncology specifically, and with medicine in general, it’s not black and white,” Dr. Davidson said. “There is a lot of leeway. There is a lot of individualism for treatment plans for patients, so problems start to happen when major insurance companies hire third-party companies to come in and do nothing but screen all your imaging and either green-light or red-light your treatment plans.”

For both of these physicians, the delay caused by the waiting game can put the patient’s health in the balance. Dr. Carter often encourages his patients to engage in the appeals process with their health insurance plan by calling the numbers listed on their insurance cards. Dr. Davidson has enlisted the assistance of his patients as well.

“When the patient calls the insurance company and gets into the conversation, it shows just how much the patient is concerned about the situation,” Dr. Carter said. “It absolutely helps for the patient to get involved and review with their insurance company what treatments have already been tried, and why they didn’t work. The patient is looking for a solution just as much as the physician.”

Fortunately, in Dr. Carter’s experience, a reply for a PA request usually takes 24 to 48 hours. Things get more complicated, however, for specialists like Dr. Davidson.

“There is more bureaucratic pressure placed on the medical practice and more delay and anxiety on the part of the patient (when dealing with PAs),” Dr. Davidson said. “We are a larger facility, and we have five full-time employees that deal with nothing but authorizations. It’s still a burden for us. I don’t know how smaller practices deal with it. Essentially your first swipe at the PA is a website, so someone is taking a patient’s medical record and actually typing it into an online form to see if it will fit exactly cookie-cutter into this form. The patient is not cookie cutter. There is no way to cookie cutter every patient, no matter what the specialty or situation.”

Some states have pursued legislative solutions to PA problems, but with little success, as insurance companies and their lobbyists come out in droves in opposition. As non-physicians increasingly attempt to dictate health care delivery, the Medical Association is committed to finding solutions to PAs and other related issues so that we keep health care decisions between doctors and patients.

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