brand logo

Fam Pract Manag. 2008;15(5):14-16

Physician wins suit, bills PBM for time spent on paperwork

An Ohio physician recently fought back against the onerous paperwork requirements of pharmacy benefit management (PBM) companies – and won. Gary Gibson, MD, sued MEDCO Health Solutions for failing to reimburse him for time spent filling out prescription inquiries. Gibson estimated that he spent 12 to 30 minutes on this task each week and billed the company $150 per hour.

In March, the court ruled that because MEDCO's prescription inquiries were designed not for patient benefit but simply to save the company money, Gibson could collect payment for his time. MEDCO tried to argue that because it is an administrator of patients' prescription drug benefits provided under their health plans, any paperwork required should be viewed as part of the physician's contracted services.

The court awarded Gibson $187.50, the amount of his lawsuit. “It sounds laughable, but the significance is as big as the quantity is small,” said Gibson, quoted in the March 18 ACP Internist Weekly. He intends to submit an invoice for additional requests he has completed since filing the lawsuit.

MEDCO has not yet announced whether it will appeal the decision.

Former senators tackle health system reform

Four powerful Washington insiders – former Senate Majority Leaders Howard Baker, Tom Daschle, Bob Dole and George Mitchell – have come together to study ways to fix the U.S. health system. Their coalition is called the Leaders' Project on the State of American Health Care, and it is expected to present its bipartisan findings next year to Congress and the winner of this year's presidential election. The Robert Wood Johnson Foundation is funding the project.

Dole outlined the four main problems the group will address. “Our goal is to develop parameters for reform and provide the necessary policy foundations to address the delivery, cost, coverage and financing challenges facing the health care system,” Dole said.

To get the project started, each former senator is holding a public forum on one of the four problem areas. In April, Daschle oversaw the first forum, which examined how to improve the quality and value of health care.

The former senators will be leaning on former aides to Presidents Bush and Clinton to guide the project. The group's codirectors are Chris Jennings, a former health care adviser to Clinton, and Mark McClellan, MD, a former Centers for Medicare & Medicaid Services administrator for Bush.

The project's leaders acknowledge that health care reform has been attempted without success many times in Washington.

“What is different now is that with each passing year, and I would argue with each passing day, the deficiencies and failures of the current system become more evident and the persons failed by that system grow in number,” Mitchell said.

Characteristics of high-performing groups

Congress considers more funds for residency programs

In addition to their closely watched efforts to stop the 10.6 percent Medicare pay cut scheduled for July 1, some federal lawmakers are also trying to address the nation's projected doctor shortage. One solution being debated is the Physician Shortage Elimination Act, which would allocate millions for expanded scholarship opportunities and residency training programs.

Researchers and medical societies have estimated that there could be a shortage of 200,000 physicians in the United States by 2020.1 For its part, the AAFP's 2006 “Workforce Reform” report concluded that the United States would need 139,531 family physicians working in 2020. To reach that level, family medicine residency programs must be graduating more than 4,400 new family physicians each year, almost double the current rate.

“It is a significant problem, which we all must address at the federal, state and local levels,” Kansas Sen. Pat Roberts told McClatchy Newspapers.

But not everyone is convinced that expanding the funding for medical education is the correct approach to addressing the predicted physician shortage. In a commentary in the April 17 New England Journal of Medicine, David C. Goodman, MD, and Elliott S. Fisher, MD, argue that the underlying problem is a “largely disorganized and fragmented delivery system characterized by lack of coordination, incomplete patient information, poor communication, uneven quality and rising costs.” They assert that “increasing the number of physicians will make our health care system worse, not better,” citing studies that found that, among other things, patient outcomes in regions with a large supply of physicians are not better than other regions.

They offer three recommendations for lawmakers:

  1. Retain the Medicare cap on funding for graduate medical education.

  2. Reallocate current medical education funding toward programs that could lead to improved care coordination and chronic-disease management;

  3. Reform payment systems so they foster integration, coordination and efficient care.

Continue Reading

More in FPM

Copyright © 2008 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.