Home Forums Discussions General Discussion Being forced to practice Bad Medicine LONG RANT

This is off the subject of AC but I know many of you are experiencing the same dilemma. I have many patients with mixed hyperlipidemias resulting in both LDL and triglyceride elevations and low HDL's. Many are also diabetic. In the past I was comfortable prescribing just about any statin along with a fenofibrate as the studies seem to indicate the risk of myopathy with this combination is small and the negative effects on blood glucose are much less than with the niacins, etc. Inevitably I would get a request for preauth for the fenofibrate and could usually get it to go through after documenting the need for a statin as well. Then I started getting denials saying the insurance would only pay for gemfibrozil and not a fenofibrate. OK, so then I would prescribe gemfibrozil and change the statin to Crestor. Those then went through for a while after obtaining a preauth.

Now, however, one insurance plan in particular insists they will not pay for either Crestor or any fenofibrate and tell me that I should prescribe gemfibrozil and pravastatin and have alluded to the patient that this is an acceptable alternative. I do not believe it is, nor do any of the studies I can find. I had a 30 minute phone conversation with a pharmacist employed by this company who was very understanding. He also said he understands and agrees with my concerns. He said they (the working pharmacists there) have taken this matter several times to "the higher ups" but have made no progress. He told me these upper level people "looked at the topic and decided it was no big deal".

Well, although I tend to agree with them clinically (I really have not seen all that many problems) my drug interaction checker, the PDR, and all the online info I can find disagree and advise me NOT to use any statin with gemfibrozil. At this point however, it is only contraindicated with simvastatin. Granted, some statins may be better than others depending on their metabolic pathway but, when there are much safer alternatives, why should I even have to concern myself with this issue?

So my question is....who is going to take the heat and have to face the jury if my patients (who have been deluded by the insurance company into believing this was my idea to use this combination of medicines) develop complications? I have spoken directly with each patient that makes the choice to use these generics rather than the Trilipx, Tricor or Crestor that I have recommended. I have documented my concerns to them. But, money talks, and my "BS" walks so most of them say they want to take what the insurance will pay for. Consequently I am feeling like I am being forced to practice bad medicine. Every day my frustrations with this profession increase. Are any others handling situations like this in a better way?

Leslie,
I generally take the path of least resistance, and whatever keeps my nurse off the Preauth hotline and keep her productive is how I have been coerced into practicing just to maintain some level of efficiency. I don't like it but have learned this is what works best for me. I really feel frustrated most days and take solace in the song by Beck--"everyone is out to get you...".
It may have to do with being 3rd in pecking order growing up and learning at an early age that being dominated by my older brother in matters of confrontation was best handled by submitting to his will, and the quicker I learned this the better we both got along.
I am learning quickly this is the way of the electronic health record as well.
No easy answers.
However, about a month ago I got a similar denial on a diabetic with multiple strokes unable to take anything but welchol, and intolerant of statins, niacin, etc. I sent out 2 letters, a nice one via updox explaining rationally of my recommendation (knowing this would get denied) and a second via mail (letting the insurance company know I will be facilitating legal counsel for my patient when she has her next stroke off the welchol) In 3 days I got approval for a year--same scenario will need to be repeated in a year--and what a waste of valuable time for all parties involved. jimmie

I have the same issues. At some level, patients have to stand up for themselves. If their doctor tells them what works best, and they still say, "I want to go cheap", then it's their funeral. Just document clearly (I have a template with legal verbiage, ("I advised this & this, for this reason, but patient requested formulary against my advice, understanding this may increase their risk of this").

The legal verbage is the key. I had a patient status post cabg who wont take a statin and swears by the red yeast...so I had him sign a note that basically says he cant blame me for anything upon his death and gave him a brochure from the undertaker nextdoor....2 weeks later he had his MI in Florida and died...a son called me on the carpet...when he saw the note...he apologised..

Nice. I get a lot of patients thinking these other therapies are equivalent or much better than 'drugs.' How fortunate for you!

I remain the renegade in the world of contracts, insurances, and formularies. I always write generically, and choose the cheapest drug when appropriate. The Wal-mart $10/90 day list is my friend. Having said that, when I can't go that route or there is a conflict with insurances, I remind them and myself that the insurance company is about money, and I am about best care. If they have chosen insurance that does not reimburse properly, it is no different from car insurance that will not pay for a repair. Yell at the insurance, or cough up the money.

I love it! I am going to have this printed on my prescription pads.

Thanks guys!