Forced Medication Changes by Pharmacies

[docB]

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We all get those calls from pharmacists (usually on patients seen by another ER doc earlier):
Pharmacist: Their plan won't cover this and they don't want to pay for it. You have to change it to something else.
Me: Well, what's wrong with them?
Pharmacist: I don't know. They're not here. You need to change it.
Me: But I didn't see them.
Pharmacist: They were seen in your ER. You need to change it.
Me: But how can I change it if I don't know what it's for?
Pharmacist: That's your problem.

This happens a lot with Augmentin. All insurance companies and Medicaid have out lawed Augmentin because they felt (in as much as they feel) that it was being overused for otitis. So now anytime I write someone for Augmentin for a dog bite I get one of these calls. I warn everyone ahead of time "It's expensive, it's what you need, your plan won't cover it." and I still get the calls. I was on the phone for an hour the other night trying to get a kid who was bit on the ear his Augmentin. Made it hard to see 2.2 per hour. I'm going to have to go back to telling them that they can pay for it, see their PMD (HA) or come back to the ER and start over.

 

[dredd]

For otitis media, you might want to try them on something like amoxicillin first. It's dirt cheap, and unless your region has a high prevalence of resistance, it should be effective. I'm no pediatrics expert, but I do recall a FP telling me that there was even some controversy regarding usage of any abx in OM. Amoxicillin may cover some of your animal bite anaerobes, but I'd be uncomfortable sending a patient on anything but augmentim or something with betalactamase inhibitior to avoid staph infections. You can get really nasty abscesses that need to be drained pretty quickly with those, and of course it can be malpractice if you end up getting the joint or bone infected. You can check to see if clindamycin or cipro is covered in their formulary sometimes too. These formularies do get to be problematic, I hate the fact that we even have to ask our patients if they have insurance, it's a whole other level to figure out what's on their formulary.

 

[ERMudPhud]

Originally posted by docB
So now anytime I write someone for Augmentin for a dog bite I get one of these calls.

The combination of PCN and Keflex provides good coverage for animal bites. Augmentin is easier to take and to write for and many articles on animal bites mention it first but if you read closely they usually also mention the PCN/Keflex combo somewhere in the fine print. We've used it for years in a patient population where nobody has insurance.

 

[docB]

Originally posted by dredd
For otitis media, you might want to try them on something like amoxicillin first.

Originally posted by ERMudPhud
The combination of PCN and Keflex provides good coverage for animal bites.

Ok, you guys misunderstood my post. I'm saying that it's a problem in the ED when pharmacists and insurance formularies are deciding what drugs can be given. It also is time consuming and a liability disaster to try to "do the right thing" and make these changes for the patient.

If I treat an otitis I do use amox. My point was that because the insurers think Augementin is overused for otitis it's been banned across the board.

Sanford lists Augentin for both dog and cat bites. It specifically says not to use Keflex for cats. Your secondaries for cats are cefurox (more $ than Augmentin) or doxy (can't give to kids). For dogs you can give clinda or clinda and Bactrim but clinda is pricy too.

In any case if anyone gets something less than first line and has a bad outcome you know they'll come for your head.
Plaintiff's attorney: "Doctor, why did you prescribe a second line drug to poor Timmy. He got an infection. I think Timmy and his family should go hang out at your house. You're not invited."

 

[dredd]

Bah. You can get sued for using a "first line" agent these days too. Did you know that the survivors of anthrax have sued the ER docs and the cipro drug manufacturing company for prescribing cipro (despite it's what the CDC reccomended)? They claim to have suffered permanent joint pain from that drug and that the doctors didn't warn them of the risk. 🙄

 

[drpcb]

doxys ok for kids over 8
we treat WAY too many dog bites unnecessarily.

I understand, however, that this was not the gist of this post. Rather, it was being placed in the awkward position mentioned by the initial poster. I feel your pain. How do you know what to change the drug to if you don't know anything about the patient? the alternative is to let them go untreated and get worse.

I tell the pharmacist that I cannot change it without seeing the patient.
I tell them to dispense enough pills (for cash, or as an advance) to hold them over until they see (haha) their PMD.
I tell them that the patient CAN pay for the pills, instead of their friggin cell phone or SUV. (Oh yes, LOTS of them are in this situation.)

If they choose not to they risk death, blahblahblah.

I sleep at night knowing I can treat compassionately, but I cannot cure the ridiculous state of health care in the US, and quite frankly, this insurance issue is the (dare I say) PATIENT'S problem, and not mine.

No I am not burned out, just realistic. We must be to stay afloat in this business.

P.S. augmentin is generic now (has been for a few years) so it's not as expensive as some of us older timers might still think.

P.P.S
Plaintiff's attorney: "Doctor, why did you prescribe a second line drug to poor Timmy. He got an infection. I think Timmy and his family should go hang out at your house. You're not invited."

defendant attorney: (at deposition, certainly not all the way to the courtroom) "My client clearly met the standard of care, and even went beyond the call to try to accomodate little Timmy's financial situation, although it is extremely unfortunate what happened to poor Timmy."

This case would an unfortunate outcome unrelated to the physician's treatment.

 

[ERMudPhud]

Originally posted by docB
Ok, you guys misunderstood my post. I'm saying that it's a problem in the ED when pharmacists and insurance formularies are deciding what drugs can be given

Your right I didn't directly address your post. Spiralling medication costs are driven in part by drug companies always pushing the newest and most expensive drugs to a population of physicians who are afraid that if they don't use the newest and most expensive they might be liable for any bad outcomes or treatment failures. I can think of lots of examples but right now there is a Nexium ad on TV (essentially the same damn drug as prilosec). One result of this is that insurance companies are forced to limit formularies to conserve costs. This is a fact of life and isn't going to go away no matter how annoying. That and the fact that many of my patients have lost all their insurance means that I always have to be aware of drug costs when writing prescriptions. If I am writing for anything even remotely expensive I always ask the patient how they will pay for it. If they will be paying for it themselves I offer them the option of the new expensive drug or something cheaper while explaining the disadvantages of the cheaper drug (QID dosing for example). Then I leave it up to them. I have the advantage of having an outpatient pharmacy in my ER so I can ask the pharmacist the cost of any drug and if the patient's insurance covers it.

When I get calls from the pharmacist to change medications I tell them I'll call them back. Then I have my clerk pull the patients chart which usually takes only a few minutes. When I have a second I look at the chart and call the pharmacy back to arrange an alternative med. In my mind its worth the time (a few minutes at most) since I've seen more than one ER bounceback come in a whole lot worse when they couldn't afford their initial prescriptions. As I said before most of my patients fill their scripts as they leave our ER so I know immediately if they can't get their meds.

Finally, antibiotics for animal bites. The best article I've seen was in the NEJM a few years ago. (Volume 340:85-92). It said in part "On the basis of our findings, we believe that empirical therapy should include a combination of a ?-lactam antibiotic and a ?-lactamase inhibitor, a second-generation cephalosporin with anaerobic activity, or combination therapy with either penicillin and a first-generation cephalosporin or clindamycin and a fluoroquinolone. When given alone, azithromycin, trovafloxacin, and the new ketolide antibiotics display in vitro activity against common aerobic and anaerobic isolates from bite wounds and thus may also be useful" The recommendation in Sanford to not use Keflex ALONE for cat bites comes from this article. If everything you needed to know about ID was in Sanford we wouldn't need ID docs. Using PCN PLUS Keflex does provide appropriate coverage and is in fact standard of care at many county hospitals. I offer patients the choice of augmentin or PCN/Keflex while explaining that the big difference is cost versus frequency of dosing.

Interestingly the above NEJM article is followed by an editorial which essentially agrees with the article and goes on to point out that this article was relevant to treatment of bite infections but not antibiotic prophylaxis. As they point out multiple attempts to show benefit to prophylaxis in DOG bites has yielded limited results and many experts don't advocates antibiotic prophylaxis for uncomplicated dog bites.

 

[ERMudPhud]

Originally posted by drpcb
P.S. augmentin is generic now (has been for a few years) so it's not as expensive as some of us older timers might still think.

Last year a friend of mine got a simple cellulites while on vacation in Long Island. The Southhampton ER wrote him for Augmentin and the local pharmacy charged him over $120 for a 10 day course. Even Sanford would say that $30 worth of Keflex would have been a fine choice for an uncomplicated cellulitis in a young patient with no other medical problems.

 

[edmadison]

Originally posted by drpcb
Plaintiff's attorney: "Doctor, why did you prescribe a second line drug to poor Timmy. He got an infection. I think Timmy and his family should go hang out at your house. You're not invited."

defendant attorney: (at deposition, certainly not all the way to the courtroom) "My client clearly met the standard of care, and even went beyond the call to try to accomodate little Timmy's financial situation, although it is extremely unfortunate what happened to poor Timmy."

This case would an unfortunate outcome unrelated to the physician's treatment.

As an attorney and a soon-to-be MD, I must disagree with this last line of reasoning. If the patient has a poor outcome and is an appealing victim to the jury, they will often look for any hook to hang their verdict on. In this case, perhaps the most respected reference lists a first-line treatment. If a choice is made to deviate from this, you'd better have a great reason for it which is documented in the chart (e.g., not picking PCN because of allergy). You and I and a panel of medical experts may agree that your choice of the second line drug was appropriate. However, when the plaintiff's attorney shows you the highlighted text in the Sanford Guide and has you read it to the jury right after you have admitted that it is the most widely accepted reference text for prescribing antibiotics -- you are going to look bad.

Take home messages: 1) lawyers suck 2) reasonable care is not in the eyes of the medical professionals, its in the eyes of the jury, 3) document deviations from guidelines/standard of care contemporaneously with treatment, 4) lawyers suck.

There will be a test over items 1 and 4.

P.S. The cross examination would look something like this.

Attorney: Dr. I'm handing you what has been marked for identification purposes as plaintiff's exhibit 23. Do you recognize it?
Dr: Yes.
Attorney: What is it?
Dr: It appears to be a copy of the 2002 Sanford Guide to Antimicrobial Therapy.
Attorney: Are you familiar with the book?
Dr: Yes.
Attorney: Is this a widely used reference by medical practitioners?
Dr: Yes.
Attorney: In fact, it is the most widely used reference of its type, correct?
Dr: I suppose so.
Attorney: An authoritative source, correct?
Dr: Yes:
Attorney: Please open the guide to page ## and read the highlighted text under animal bites/primary treatment.
Dr: ... [the dr. reads].....
Attorney: Yes or No, Doctor. Did you prescribe the first line therapy as designated by the authoritative source?
Dr: No
Attorney: In your note in the medical record, did you record a reason for not giving the first line therapy?
Dr: I did not, but my reason was ...
Attorney: Yes or No please doctor.
Dr:No
Attorney: Your Honor, I move the addmission of exhibit 23, I have no further questions.

You see, simply by very specific questions in the right order, a perfectly reasonable choice can be effectively attacked.

Ed

 

[ERMudPhud]

Originally posted by edmadison

P.S. The cross examination would look something like this.

Attorney: Dr. I'm handing you what has been marked for identification purposes as plaintiff's exhibit 23. Do you recognize it?
Dr: Yes.
Attorney: What is it?
Dr: It appears to be a copy of the 2002 Sanford Guide to Antimicrobial Therapy.
Attorney: Are you familiar with the book?
Dr: Yes.
Attorney: Is this a widely used reference by medical practitioners?
Dr: Yes.
Attorney: In fact, it is the most widely used reference of its type, correct?
Dr: I suppose so.
Attorney: An authoritative source, correct?
Dr: Yes:
Attorney: Please open the guide to page ## and read the highlighted text under animal bites/primary treatment.
Dr: ... [the dr. reads].....
Attorney: Yes or No, Doctor. Did you prescribe the first line therapy as designated by the authoritative source?
Dr: No
Attorney: In your note in the medical record, did you record a reason for not giving the first line therapy?
Dr: I did not, but my reason was ...
Attorney: Yes or No please doctor.
Dr:No
Attorney: Your Honor, I move the addmission of exhibit 23, I have no further questions.

You see, simply by very specific questions in the right order, a perfectly reasonable choice can be effectively attacked.

Ed

Hopefully a good defense attorney would point out the quote I posted from NEJM showing multiple equal options for treatment of bite wounds. That being said when I give PCN/Keflex I always document that I offered a script for Augmentin and explained that its primary benefit was that it is easier to take but that they chose PCN/Keflex because it was less expensive.

 

[FoughtFyr]

Originally posted by ERMudPhud
Hopefully a good defense attorney would point out the quote I posted from NEJM showing multiple equal options for treatment of bite wounds.

With all due respect, you would have already lost. Juries are not doctors, the realities of clinical judgement and literature review are not in their experience. "Second line treatment" they understand, especially in the face of a sympathetic plantiff. I think it was Cicero who said "when the truth is on your side, weild it as a sword. When it not, shield yourself with emotion..." That seems to be the principle of malpractice law these days.

- H

 

[neutropeniaboy]

P.S. The cross examination would look something like this.

Attorney: Dr. I'm handing you what has been marked for identification purposes as plaintiff's exhibit 23. Do you recognize it?
Dr: Yes.
Attorney: What is it?
Dr: It appears to be a copy of the 2002 Sanford Guide to Antimicrobial Therapy.
Attorney: Are you familiar with the book?
Dr: Yes.
Attorney: Is this a widely used reference by medical practitioners?
Dr: Yes.
Attorney: In fact, it is the most widely used reference of its type, correct?
Dr: I suppose so.
Attorney: An authoritative source, correct?
Dr: Yes:



Mistake.

He should have not said "yes." Big error, as it is not authoritative. The Stanford Guide is simply a collection of recommendations based on a review panel's interpretation of available literature.

It, like any other textbook, is by no means authoritative.

 

[neutropeniaboy]

Originally posted by docB
This happens a lot with Augmentin. All insurance companies and Medicaid have out lawed Augmentin because they felt (in as much as they feel) that it was being overused for otitis.

Well, it is.

 

[Apollyon]

Originally posted by neutropeniaboy
Mistake.

He should have not said "yes." Big error, as it is not authoritative. The Stanford Guide is simply a collection of recommendations based on a review panel's interpretation of available literature.

It, like any other textbook, is by no means authoritative.

Well, "authoritative" is "of acknowledged accuracy or excellence". No attorney asks a question he doesn't know the answer to. Believe me, lawyers are masters of semantics. If you say "no", then you have to say what IS "authoritative". You say there is no such thing, and the lawyer throws the definition at you, and then questions what IS your source, if not this book that is read by thousands of practitioners. Your memory? Then he asks, "Have you ever made a medication error?" --> you have already lost: you say "yes", you may be wrong again right now, you say "no", you stretch your credibility.

Oh, and, don't forget perjury: if a doctor does indeed think Sanford is "authoritative", but says it isn't, that's a felony. If the doc says, "no, it's not authoritative", the plaintiff's counsel sub poenas a nurse or tech from your ED, and that person says how you have used that book "on every shift I've ever worked with him on". Then, if it is not such a good source, why do you rely on it so heavily?

It's all slimy.

 

[docB]

Originally posted by neutropeniaboy
Well, it is.

Oh for crying out loud. You guys sure do miss the forest for the trees. Yes, amox is the first line. Yes Augmentin has been overused for otitis. My point (again) is that by restricting Augmentin they have made it almost impossible to get even for actual indications like animal bites.

 

[edmadison]

O.K. neutrapeniaboy, here's what you get when you go down that line...

Attorney: An authorative source, correct?
Doctor: No.
Attorney: Are you aware that the Sanford guide has a circulation of over 4 million*?
Doctor: If you say so.
Attorney: Would you be surprised that it was distributed in over 100 countries?
Doctor: No
Attorney: That, in fact, it is the second most widely distributed reference guide, second only to the Physician's Desk Reference?
Doctor: Ok.
Attorney: So even though its used by a large proportion of the medical community it is not an authoritative resource?
Doctor: No, it is not.
Attorney: Incidently, Doctor, do you own a copy of the Sanford Guide?
Doctor: Yes.
Attorney: Please open the guide.....

You see, by arguing over a largely semantic point, the doctor comes off looking evasive and arrogant. Not only that, but the evidence still comes in! The doctor just made a much bigger deal about it. Further, now that it has been brought up, every physician witness is going to be asked his or her opinion of the guide and most will agree that it is an authoritative source. By arguing the doctor has only helped the plaintiff's case. And for what? The issue is community standard of care. Even though the guide isn't a primary source or even a text book, it is still a well accepted resource. If everybody's using it, it kind of becomes the standard of care (subject to rebuttle of course).

A much better course is to go along with the line of questioning and then get your side of the story out on re-direct examination. That way, the reasoning can be explained in a non-hostile way. You can also make the plaintiff's attorney look bad by noting that the issue is more complex than a simple line in a resource. The problem is that doctors are arrogant. They think they are smarter than the attorneys. They are usually right. However, the rules of court are fixed against the witness. Doctor's think they can win the game. In actuality, they can't even get on the field.

Just one other point for Apollyon, you actually can't call witnesses to testify on whether the doctor used the guide or not. This is known as impeaching on a collateral issue. In general, it is not allowed because otherwise you end up going down the sidepaths too much. In actuality, you would already know how much the doctor used the guide because you would have asked during depositions. If the doc deviated from that, you can use the transcript to impeach the witness.

Ed

 

[Apollyon]

Originally posted by edmadison
Just one other point for Apollyon, you actually can't call witnesses to testify on whether the doctor used the guide or not. This is known as impeaching on a collateral issue. In general, it is not allowed because otherwise you end up going down the sidepaths too much. In actuality, you would already know how much the doctor used the guide because you would have asked during depositions. If the doc deviated from that, you can use the transcript to impeach the witness.

I stand corrected, and thank you for that. Your response was concise, yet you don't speak ex cathedris, so it doesn't sound stuffy or arrogant.

 

[juddson]

I think these cross dialogues are really convincing. But they aren't realistic in the sense that the issue would have been fully anticipated by the defense and explored during depositions and direct examination. The doctor isn't as helpless as these crosses suggest s/he is.

Judd

 

[edmadison]

Originally posted by juddson
I think these cross dialogues are really convincing. But they aren't realistic in the sense that the issue would have been fully anticipated by the defense and explored during depositions and direct examination. The doctor isn't as helpless as these crosses suggest s/he is.

Judd

We maybe not completely, but the witness is extremely disadvantaged on cross examination. Witnesses who don't try to get over on the attorneys do much better than those who think they are smart. That's where the trouble is.

Ed

 

[juddson]

Originally posted by edmadison
Witnesses who don't try to get over on the attorneys do much better than those who think they are smart. That's where the trouble is.

Ed [/B]

agreed.

Judd

 

[neutropeniaboy]

Originally posted by Apollyon
Well, "authoritative" is "of acknowledged accuracy or excellence". No attorney asks a question he doesn't know the answer to. Believe me, lawyers are masters of semantics. If you say "no", then you have to say what IS "authoritative".


No, you don't. That's the entire point. The lawyer is pinning you down in the hopes that you will a) state to the jury that there is a "final say" in how things are done and that b) you didn't follow the procedure.

I think you've never been deposed before. I have. Lawyers are very manipulative. I've read my own transcripts before. It's unbelievable some of the things I said after the same question was posed in several different ways.

I've been coached by my own father, a medical malpractice attorney, and other attorneys (as well as physicians) about what is deployed in the court room in order to obtain the answer a lawyer wants.


You say there is no such thing, and the lawyer throws the definition at you, and then questions what IS your source, if not this book that is read by thousands of practitioners. Your memory? Then he asks, "Have you ever made a medication error?" --> you have already lost: you say "yes", you may be wrong again right now, you say "no", you stretch your credibility.


I think you'd really fall apart on a cross-examination. You really don't know how to address these questions. Lawyers ask vague questions.

[/B]

 

[Apollyon]

Originally posted by neutropeniaboy
I think you'd really fall apart on a cross-examination. You really don't know how to address these questions. Lawyers ask vague questions.

You must be insufferable in reality. And I didn't fall apart on cross. Didn't do great, but didn't go to pieces.

And the line about making errors or not stretching credibility comes from an attorney.

Try not speaking ex cathedris.