Post by unlawflcombatnt on Dec 18, 2008 18:15:47 GMT -6
Today I ran into my 1st case of a Medicare Part D carrier trying to practice Medicine without a medical license.
CAREMARK, a provider of Part D Medicare, has decided that it knows more about practicing Medicine than I do (Despite the fact that I actually have a California Medical License, while CAREMARK does not.)
After having written ~30 prescriptions for an anti-diabetes drug called Actos® (pioglitazone), I had a prescription for Actos denied today, because it was
"not covered."
Until today, I hadn't been aware that Medicare Prescription Drug carriers were vetoing any decisions by M.D.s on how to treat patients. Stupid me, I thought only doctors made medical treatment decisions. (What was I thinking!?)
In this particular case, there is NO other equivalent drug. Unlike all other anti-DM drugs (except Metformin), there is no risk of causing hypoglycemia with Actos® (pioglitazone).
Though Metformin also does not cause hypoglycemia, it can cause potentially fatal lactic acidosis. The risk is so high that Metformin is contraindicated in patients over 80, patients with renal failure, and patients that are dehydrated (the incidence of some degree of dehydration is roughly 50% in elderly patients--which is almost 100% of the patients I treat.) In addition, dehydration is far more common in diabetics to begin with, as hyperglycemia causes dehydration by increasing urination.
Metformin is also contraindicated in any patients where hypoxemia occurs, or is a possibility, such as Chronic Obstructive Pulmonary Disease (COPD). Since the patient in question has COPD, which causes chronic hypoxemia, Metformin is contraindicated in his case.
But to make Metformin even more intolerable, the PDR states that the incidence of diarrhea with Metformin is 53%, while the incidence of nausea/vomiting is 25%.
Just the kind of drug you want to give to a poorly compliant patient--one that gives him the runs or makes him barf! Or both.
My other (covered) option was glyburide, which is an oral diabetes drug that can easily cause hypoglycemia, especially in poorly compliant patients. Severe hypoglycemia is FATAL--and it is fatal IMMEDIATELY. I've already seen patients that died from fatal hypoglycemia from drugs such as glyburide, so I know that lethal hypoglycemia is a genuine risk.
To reduce the risk, it's necessary to monitor patients closely, and it's very necessary for patients to make & keep follow up appointments.
If patients cannot comply with follow ups and medication instructions, glyburide and related drugs are VERY risky.
Since my patient was prescribed treatment by another doctor for diabetes over a year ago, and never took the medication, I already knew he was non-compliant. And to bolster that claim, the patient didn't bring his Actos® prescription to the pharmacy until 2 weeks after it was written. Thus, there's little question that patient compliance will be a problem.
Oh, I almost forgot. The patient lives about 70 miles away from the office. So it should only take him about 2 hours to get to the office in Southern California traffic, and 2 hours to get home. Surely he won't mind making frequent, 4-hour round trips to see the doctor. Surely his employer won't mind him taking an entire day off every 2 weeks to see his doctor.
So my own trained medical opinion was to start the patient on Actos® (pioglitazone), as it will not cause hypoglycemia, and will not kill him if he either misses doses or takes too much at one time.
But apparently "Dr. CAREMARK" knows more about it than I do. I guess if you have enough money and political clout, you can practice medicine without a license.
I recommend that anyone considering a Medicare Prescription Drug Plan avoid CAREMARK like the plague.
CAREMARK, a provider of Part D Medicare, has decided that it knows more about practicing Medicine than I do (Despite the fact that I actually have a California Medical License, while CAREMARK does not.)
After having written ~30 prescriptions for an anti-diabetes drug called Actos® (pioglitazone), I had a prescription for Actos denied today, because it was
"not covered."
Until today, I hadn't been aware that Medicare Prescription Drug carriers were vetoing any decisions by M.D.s on how to treat patients. Stupid me, I thought only doctors made medical treatment decisions. (What was I thinking!?)
In this particular case, there is NO other equivalent drug. Unlike all other anti-DM drugs (except Metformin), there is no risk of causing hypoglycemia with Actos® (pioglitazone).
Though Metformin also does not cause hypoglycemia, it can cause potentially fatal lactic acidosis. The risk is so high that Metformin is contraindicated in patients over 80, patients with renal failure, and patients that are dehydrated (the incidence of some degree of dehydration is roughly 50% in elderly patients--which is almost 100% of the patients I treat.) In addition, dehydration is far more common in diabetics to begin with, as hyperglycemia causes dehydration by increasing urination.
Metformin is also contraindicated in any patients where hypoxemia occurs, or is a possibility, such as Chronic Obstructive Pulmonary Disease (COPD). Since the patient in question has COPD, which causes chronic hypoxemia, Metformin is contraindicated in his case.
But to make Metformin even more intolerable, the PDR states that the incidence of diarrhea with Metformin is 53%, while the incidence of nausea/vomiting is 25%.
Just the kind of drug you want to give to a poorly compliant patient--one that gives him the runs or makes him barf! Or both.
My other (covered) option was glyburide, which is an oral diabetes drug that can easily cause hypoglycemia, especially in poorly compliant patients. Severe hypoglycemia is FATAL--and it is fatal IMMEDIATELY. I've already seen patients that died from fatal hypoglycemia from drugs such as glyburide, so I know that lethal hypoglycemia is a genuine risk.
To reduce the risk, it's necessary to monitor patients closely, and it's very necessary for patients to make & keep follow up appointments.
If patients cannot comply with follow ups and medication instructions, glyburide and related drugs are VERY risky.
Since my patient was prescribed treatment by another doctor for diabetes over a year ago, and never took the medication, I already knew he was non-compliant. And to bolster that claim, the patient didn't bring his Actos® prescription to the pharmacy until 2 weeks after it was written. Thus, there's little question that patient compliance will be a problem.
Oh, I almost forgot. The patient lives about 70 miles away from the office. So it should only take him about 2 hours to get to the office in Southern California traffic, and 2 hours to get home. Surely he won't mind making frequent, 4-hour round trips to see the doctor. Surely his employer won't mind him taking an entire day off every 2 weeks to see his doctor.
So my own trained medical opinion was to start the patient on Actos® (pioglitazone), as it will not cause hypoglycemia, and will not kill him if he either misses doses or takes too much at one time.
But apparently "Dr. CAREMARK" knows more about it than I do. I guess if you have enough money and political clout, you can practice medicine without a license.
I recommend that anyone considering a Medicare Prescription Drug Plan avoid CAREMARK like the plague.