Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, August 07, 2008

The Latest Craziness

Old man in atrial fibrillation orders his Coumadin from a mail-order pharmacy benefit manager. (I tried to send him to Walmart, or even Tar-jay, where they have even better deals, but he doesn't drive.) His INRs, measured monthly, range between 2.4 and 2.6 (ie, perfect.) Early last month we faxed refills for the Coumadin and his ToprolXL to the mail-order PBM, per his request. For some unknown reason, they ship his ToprolXL but not the Coumadin.

He called us. We faxed it again two weeks later. We also called in a thirty-day supply to his local pharmacy to hold him until it arrived.

Today he calls again: still no Coumadin in the mail. So we call the PBM. Four departments and six idiots later, we hear this about his prescribed dosage of 3 mg/day, except for 4.5 mg on Sundays:
That's considered high for his age.
See the gouges in the desktop from my saurian claws of outrage as I reply through clenched teeth:
His INRs are therapeutic and monitored regularly.
Aren't you proud of me for sucking back the words, "You ignorant fucktard!"


At Thu Aug 07, 08:00:00 AM, Blogger Elaine said...

Very proud indeed.

Watch your blood pressure, thoough.

At Thu Aug 07, 08:29:00 AM, Anonymous Anonymous said...

"Fucktard". I like that one. I will use it on a few fucktards at my poker game tonight. Thanks.

At Thu Aug 07, 09:37:00 AM, Blogger mark's tails said...

I would have been more proud if you said it ;)

At Thu Aug 07, 10:20:00 AM, Anonymous Anonymous said...

"Listen up, you moldy douchebag: I've got the MD, I'm managing his care, and you've got the IQ of a fungus-ridden swipe of dogshit. Fill the fucking prescription, and quit second-guessing me, or I'll come over there and jam that fax machine so far up your squeakhole you'll be farting toner clouds for the next six months."

At Thu Aug 07, 11:05:00 AM, Anonymous Anonymous said...

As a non-mail order pharmacist, you should have said what you were thinking!!!!!

The way these places operate, a technician (with a high school education only) enters the order & sees the alert of "high dose for age". The technician then puts the rx on hold & sends it to the pharmacist with a note - high dose, put on hold. The pharmacist, at the very least, should have sent back a request to confirm the dose while sending a 2 week supply. (As a local retail pharmacist, I send faxes to confirm doses &/or missing strengths all the time - but never send a pt without a drug unless its a sertraline/selegiline kind of interaction & the pt says he thinks he's supposed to take both). Chances are, the pharmacist just pushed it through & put the rx on hold. They don't take responsibility for care anymore than ordering your socks online will assure you from getting atheletes foot.

Either the pharmacist never reviewed the patients profile (which is NOT a surprise) or the pharmacist is just damn lazy - either one - the pt has a bad mail order PBM!

This is why pharmacists in the community want the playing field leveled!!! Mail order PBMs will often offer 90 day supply for a 60 day co-pay. Pt gets one month "free" - or one month every quarter of "headaches". Think of how many rxs you need to call into local pharmacies in Nov & Dec because the PBM order gets lost or delayed in the crush of holiday mail. There should not be a monetary incentive to use or not use a medical or pharmaceutical provider. Some folks have valid reasons to use mail order - often those who travel frequently. It often serves them well, but so can I - I just mail their rxs monthly to whereever they want them mailed.

Pharmacy should be regarded just as medicine. As a physician, you cannot do a consult by telephone on a new patient & order medications - you need to actually see them, assess them physically, etc - all the stuff you need to do to properly diagnose their disease or monitor their health (I make no claims to being a physician!).

Likewise, medication is not like buying canned corn or a parka from LLBean. You should have a face-to-face encounter with a pharmacist, particulary on a first fill of medication. We encourage patients to not doctor shop to maintain continuity of medical care. Likewise, we encourage patients to maintain one pharmacy to maintain the same care, but with their medications. This avoids interactions, helps them with problems, gives each of you a name & a face to talk to. Its much more difficult to call me a name when you know me - even though I might upset you at times.

I've got many physicians as patients and when they know I'll match Walmart, Costco & PBM prices - they encourage their patients to use the local pharmacy. We even deliver medications at no cost!

Stop by & speak with your local pharmacist sometime & see if you can work out some kind of arrangement for your patients. You'd be surprised how much they're willing to work to keep your patients & their care "close to home".

Oh - and when the time comes to vote against special deals for PBMs - do your patient a favor & vote no.

At Thu Aug 07, 12:17:00 PM, Anonymous Anonymous said...

The problem is - most of the insurers nowadays wouldn't pay for more than 2 months if you don't use a specific mail order pharmacy. Basically, after the first two months, if you don't use mail order, you have to pay the full cost.

BTW - my mom also had an episode of aetrial fibrillation and her dose of Coumadin is 6mg, but it keeps her INR at lower border of recommended range - around 2.0 - because of her wet macular degeneration and the risk of bleeding in the eye and immediate blindness. She's never had problems with her mail order pharmacy, in spite of higher dose.

At Thu Aug 07, 12:53:00 PM, Blogger Lynn Price said...

I'll come over there and jam that fax machine so far up your squeakhole you'll be farting toner clouds for the next six months."
Dammit, crankyprof does it again - I laughed a Twinkie straight through my nose. Unwrapped, of course. Cranky, how would you like to be my new editor?

At Thu Aug 07, 12:55:00 PM, Blogger knitalot3 said...

You should have said it.

I know someone that is on 10 mg per day and his blood levels are right on.


At Thu Aug 07, 06:16:00 PM, Blogger CaShThoMa said...

I admire your restraint; I wouldn't have been able to be this 'professional'. This is exactly the sort of 's...' that takes up way too much of our precious time and puts our patients at risk. I like what crankyprof had to say; whoa...I second the emotion!

At Fri Aug 08, 10:37:00 AM, Blogger rlbates said...

Could not begin to match the above commentors -- love them and your posts.


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