Practicing medicine is nothing short of variety. No two patients are alike and rarely do our patients follow treatment algorithms exactly. Some may still say this is the “art” of what we tap into as clinicians. I enjoy that I get to see patients for one complaint and diagnose them with something that unifies several other complaints they have. I feel like I “do” something when I start a treatment, because the conditions and symptoms I treat as a rheumatologist are tangible.
However, insurance companies do not like when I want to treat something that is not within the confines of my specialty. I see patients with all kinds of rashes, but I am not a dermatologist. I see patients with renal disease, but I do not manage blood pressure. Now more than ever, red tape and prior authorizations have become a way of restricting clinicians to our lanes. This is especially true when more expensive medications like biologics are prescribed. We have entered a time in medicine, and finally in rheumatology, when we are able to use medications to prevent (or at least delay the progression of) diseases that can lead to severe disability and organ dysfunction. Much like we have used statins to prevent severe coronary artery disease, we have now entered the era when we can use biologics to prevent joint damage and decrease long-term inflammatory consequences that contribute to poorer outcomes, like renal failure. However, these medications are significantly limited by the increasing restrictions of insurance plans and pharmacy benefit managers. And while more restrictions are being placed on who can prescribe what, we are caring for more patients with overlapping conditions in a system that does not reward medical complexity or support multidisciplinary comanagement.
There are restrictions appropriately set for safety. Don’t get me wrong, as a rheumatologist, I am not the best person to be prescribing antiarrhythmic medications. And I would not want someone who is not versed in the nuances of immunosuppressants to casually prescribe medications that can inadvertently suppress a patient’s bone marrow without monitoring for these possible side effects. However, some of our more dangerous drugs are available at your local pharmacy and anyone can prescribe them, regardless of specialty. Despite biologics being safer to use, though more expensive, the prior authorization process acts as a gatekeeper for only select specialists to use in select instances.
However, there are many specialties that cross paths, both in regards to preserving organ systems, and with the same medications. So where does one lane end and another begin when we use the same treatment but for different diseases? Why does an insurance company get to dictate if I am capable of using a treatment for one disease (psoriatic arthritis) but not another (plaque psoriasis) when the dose of the medication is exactly the same?
When I was training to become a rheumatologist, we had a combined clinic with dermatology and one with pulmonology. At an academic tertiary care center, I had exposure to diseases that cross fields. And at some point, there is not a field of medicine that rheumatologists do not interact with. I have even had conversations with toxicology and poison control. Yet, my day-to-day interactions with patients now that I am in private practice consist of identifying a need that my patients have and trying to fill that need when they do not have access to combined clinics. Some patients travel hours and wait months to see me, so why would I have them wait possibly longer to see another specialist that can treat the same condition I can? This is the very definition of prolonging care and contributing to the mistrust patients have in our current medical system. And fewer patients are seen in multispecialty practices within larger health systems due to the difficulty of coordinating care between highly in-demand specialty fields. Patients are not looking for more office visits, more copays, and more back and forth with multiple physicians who are treating the same condition. I find it so much more satisfying to see a patient and provide them with value-based care so they can go on living their lives the way they want to, with fewer medical bills and better outcomes because I did not make them wait before we started treatment.
As much as we like to believe these prescribing restrictions are enforced for safety, this rule can also inhibit the ability to provide good care for patients who do not have access to the other specialist, or if that other specialist referred the patient out for treatment. There are more and more instances when medications that I am trained to use are denied by insurance companies because I am not a dermatologist, for example. As a rheumatologist, my specialty is to use biologic medications and immunosuppression to decrease immune system reactivity. I can treat a patient with lupus nephritis with the same tools as a nephrologist, but I am not able to treat a patient with plaque psoriasis if they do not also have psoriatic arthritis. Conversely, I work very closely with my ophthalmology colleagues to treat uveitis and will be the one prescribing treatment for a condition that they “see” (yes, that pun was intended!). There are now programs in which weight loss medications are being prescribed by surgeons because they have a vested interest in better outcomes for their patients. In the best scenario, comanagement results in better long-term care. Increasingly though, with the consumer rise in health care costs, more and more patients are declining to participate in multispecialty visits when one primary prescriber is providing them with the treatment and outcome they desire.
So where does this line cross? It may be blurry still, with conditions that cross specialties like psoriasis and psoriatic arthritis, lupus and lupus nephritis, interstitial lung disease and rheumatoid arthritis, and even gout. How can we assure our patients and insurance companies alike that when a medication is FDA approved and indicated for one disease, that a trained clinician can treat another approved condition with the same medication, especially if those fields overlap? Is it a matter of wanting to? Or do we see this as an ethical dilemma when we have short office visits and more complex patients to treat?
What does help move the needle forward in health care is the quality of the care we provide as clinicians. We can show that working with the tools and knowledge we have to provide the best care we can when the patient is in front of us will actually save money and resources in the long term. The more often we use treatments that are medically necessary, the more we can justify to insurance companies that we are safely able to prescribe appropriate therapy. We should not limit comanagement or the concept of a team approach to health care, but we can facilitate the beginning of a therapy and coordinate care with the other specialties that should be involved in that patient’s care. There are times to practice by the rules and there are times that the rules pose unnecessary restrictions to the benefit that we can offer our communities. When you think about your own health care and if the patient is now you, what kind of advocate would you prefer to have?
When do you decide to "cross the line" in treating patients? Share in the comments.
Dr. Brittany Panico is a rheumatologist in Phoenix, AZ. She is a wife and mother of three awesome boys and enjoys hiking, being outdoors, traveling, and reading. She posts on @AZRheumDoc on Instagram and Brittany Panico, DO, on LinkedIn. Dr. Panico is a 2023–2024 Doximity Op-Med Fellow.
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