Pharmacists Gone Wild

(Facts altered to disguise cases.)

• A patient relates that her pharmacist told her if the increased dose of her medication failed to produce improvement in her symptoms after 21 days at the higher dose, she should revert back to the original dose.
• A pharmacist faxes me to ask the diagnosis of a patient, even though the patient pays cash for the prescription, and there is not insurance company involvement.
• A pharmacist tells a patient that a drug I frequently prescribe can be very sedating, when in fact most patients complain that it does not sedate them enough.

Everyone seems to want to play doctor these days, but how much do we want pharmacists to get into that role? There is something to be said for having each of every patient's diagnoses accessible from the pharmacy data bank. For example, it might prevent an asthmatic patient from using a potentially fatal beta blocker. But can we trust them with psychiatric or substance use disorder diagnoses? My patients already complain about pharmacists talking about such diagnoses where other customers can hear.

The first item above appears to clearly involve exceeding the boundaries of a pharmacist's competence and authority. This probably has happened as long as their have been pharmacists, but does the current climate encourage non-physicians to take liberties, possibly to the detriment of patients?

Get This Doc Out of the Pharmacy Loop

• Patient leaves request for refill with pharmacy.
• Pharmacy faxes me request for refill authorization.
• Patient goes to pharmacy expecting to pick refill which is not there.
• Patient leaves message on my voice mail: "Where's my refill!?"
• I retrieve voice mail.
• I call pharmacy: a) I did not receive refill request or b) Pharmacy did not send refill request
• Pharmacy faxes refill request.
• I fax refill or order via eprescribing service.

 I suggested a solution to tech support at the eprescribing service I have been using, allscripts.com: Give the patient limited access to and control over the refill process. Instead of calling the pharmacy the patient would access her account at the eprescribing Web site. She would click on the prescription she wanted to refill and indicate the name of the pharmacy she wanted to use. My eprescibing service alerts me to the request. I access the Web site, check the patient's name, the drug, last date filled, etc. With a click I authorize the refill, and the pharmacy receives the order. The system alerts the patient who can check the status of the whole process at any time, and may opt for email notification from the pharmacy when the prescription has been prepared for pick up. The system could even alert the patient if there is a problem, like the medication is not in stock. The patient can then select a different pharmacy.

What do you think?

What is a REfill?

You’ve gotta love iscribe.com.

It always seemed clear to me:

“Do NOT refill.” at the bottom of my prescriptions.

For years it must have been clear to pharmacists. Then, inexplicably, at a pharmacy in a small town where I had placed the same order for the same patient every month for years, a pharmacist who otherwise seems to speak and understand the English language (unlike too many pharmacists), decided that I must have faxed the prescription order, complete with number of pills to dispense, just to tell them not to fill it.

Like I would waste my time doing that when I could be blogging or tweeting.

I had to look at the prescription again. It did not say, “Do not fill.” It said do not REfill. By telephone I assured the pharmacist that I did in fact want the drug dispensed to the patient. Once.

Then it happened again at a different pharmacy.

I contacted the state pharmacy board. Confirming my belief, a gentleman there told me that indeed fill or order means dispense while REfill means dispense again at a later time. When the patient contacts the pharmacy. Without contacting the doctor again.

Just to avoid further wasted time I changed the prescription form for these language-challenged pharmacies to:

“Refills: zero”

So far it seems to work.

William Safire must be turning over in his grave.

It seems I am not alone. For almost a year now when iscribe.com, the e-prescribing service I use most, contacted me via the Web with a refill authorization request, the form demanded that I specify the number of REfills. Alas, iscribe, too, has cried “uncle” in the face of prescribing illiteracy, apparently dumbing down in an attempt to avoid confusion. Today the iscribe refill authorization form reads:

“Total # of dispensings:”

Let’s hope we can all agree on what that means.

Prescription Preauthorization: The New Medical Emergency

It’s 5 PM Friday, and you’re closing the office for the weekend when you receive a fax from a local pharmacy informing you that you must call an 800 number or complete a form for your patient’s health insurance company or there will be no reimbursement for the drug you prescribed earlier in the day. The patient, who may still be waiting in the pharmacy, needs a 3 month supply to take on a trip to England leaving early Saturday morning. Emergency!

The insurer is placing you in the awkward position of choosing between compliance with the demands of an entity with which you may have no direct relationship, possibly compromising your relationship with your patient, or leaving your patient with no access to needed medication for three months unless the patient elects to pay cash for what insurance might – or might not – pay for if you jump through enough hoops. Your patient will also likely expect you to say whatever it takes to get reimbursement.

When the pharmacist provides you with an 800 number you must call for preauthorization she probably thinks she is helping you. I think it’s rude and presumptuous, and a waste of time for the pharmacist. The pharmacist should ask the patient or the insurer to contact the physician. Most insurers seem to offer a choice of telephone contact or completion of a form to be returned to the insurer.

Let’s do some reality testing. As physician your duty is to the patient, to diagnose and treat, not to obtain reimbursement or to help an insurance company make a decision about reimbursement. You do have a duty to provide a copy of the medical record to whomever your patient wishes. The high cost of prescription drugs is a product of our free market economy. Don’t accept responsibility for that. Neither should you feel responsible for knowing the prices of every drug available. (I admit, though, that I do tell my patients they can get fluoxetine, paroxetine and citalopram for only $4 a month at some pharmacies!) You as physician have no duty to expend your time in order to help the payer complete a process that will enable them to deny reimbursement and improve their bottom line. You certainly should not distort the facts (lie) to get the insurer to pay for the medication. A written contract governs the patient’s relationship with the payer. The patient has agreed to the terms of that contract, and the patient, not the physician, is responsible for knowing whether the payer can demand preauthorization.

Potential for negative health consequences, not financial consequences, makes for medical emergency. Request for preauthorization does not qualify. Preauthorization, like other reimbursement related matters, should assume low priority in your practice compared to clinical matters. Accomplishing it during the next business week should suffice. If we refuse to treat these requests as emergencies, payers can develop more reasonable approaches, for example by paying for the first prescription without preauthorization but notifying the patient that future orders will require review. Furthermore, regardless of how pharmacist, physician and patient respond, the preauthorization process may lead to costly delays, even threat to the health of the patient, and may lead to necessity of another contact between physician and patient to discuss an alternative, affordable, treatment.

Before you engage in providing preauthorization information to a payer your patient should understand that, assuming you provide correct information, reimbursement may still be denied, and that this is not the physician’s responsibility. The patient should pay the physician for this service. You should offer to simply provide a copy of your record to the payer in lieu of answering questions on a form or by telephone. Let the payer decide whether to reimburse based on the entire record instead of your answers to a few questions. Since this involves providing more – or at least different – information, with different implications, than what you routinely provide with a claim form, you should obtain from the patient separate informed consent for release.

In my practice I contract with no payers. My initial application and policy statement informs patients that I charge a $50 fee for preauthorization, payable in advance, and that the patient must first agree to the terms outlined in my preauthorization form, which states that I will provide a copy of the record at no charge instead and that the payer may still deny reimbursement. I also tell my patients to call the pharmacy to make sure the prescription is ready before going to pick it up.

Third party payers will respond to complaints from subscribers, not from physicians or pharmacists. By caving in to escalating demands from payers providers validate and enable policies that only transfer costs from insurers to patient, pharmacist and physician. The role of a physician is to diagnose and treat illness, not to obtain reimbursement. Don’t enable insurers to manipulate you or to redefine medical emergency. We must also honor patient requests to provide records to insurance companies, but by engaging in the preauthorization process without being paid by the patient we may transgress ethical boundaries. Patients should pay a nominal fee for physician participation in any review process with full understanding that the physician accepts no responsibility for the outcome. Only when physicians take control of this process will our patients demand reasonable behavior from insurance companies. And this is another good reason to avoid contracting with them.