Random Thoughts from a Restless Mind

The great Dick Lindstrom recently posted an editorial on the challenges faced by doctors in a world that is focused solely on the cost of medication, one in which pressure is brought to bear on both doctor and patient to use an inexpensive generic at all times. Dr. Lindstrom reaffirms his career-long position that only one factor matters in the complex decision making process that is medicine: what is best for my patient’s health is my sole concern. Indeed, it is important for each physician to fight for this outcome, to fight for the person who sits before us in the exam chair or beneath us on the operating table. When a clinical difference exists between the expensive branded medicine and the cheaper generic we are honor and duty bound to prescribe and support the better medicine.

Sigh. It’s just all so tiresome, this battle. We physicians certainly did not choose this fight, and frankly most of us have no dog in the fight other than the best interests of our patients. I wrote PREVIOUSLY that the notion that pens, penlights, and candlelight dinners prompt doctors to become shills for pharmaceutical companies is farcical and offensive. Come on…I’m gonna look for a reason to prescribe some new eyedrop because someone dropped off a couple of pens? That’s all silly enough, but the battle has escalated with the entry of insurance company and government programs that automatically switch to a less expensive “therapeutically equivalent” medication and then require doctors to personally run the gauntlet necessary to “justify” their clinical decisions.

We are on the receiving end of the same kind of stuff that big companies use to defeat smaller foes in court: we are bombed with paperwork. Not only that but it’s carpet bombing, indiscriminate deluges of time bombs meant to bludgeon doctors into submission. There’s collateral damage, just like in carpet bombing, only the casualties are more subtle. Forcing doctors to be a part of this irreparably damages the doctor-patient relationship, making it more of a commercial interaction as doctor becomes ombudsman for patient.

As Dr. Lindstrom exhorts, I’ve been fighting the good fight. Dr. Lindstrom doesn’t need this fight. He’s a living legend who has earned the right to stand aside from these types of petty issues and to choose to put his considerable gravitas to work on stuff that has to be more fun. Yet he willingly takes on this battle and I’ve followed his lead. Standing my ground and insisting on newer branded meds when they are superior to older, cheaper generics. It’s getting to me, though. I’m tired. My staff is tired.

I surrender. Up goes another white flag.

I’m going to surrender in the battlefield of Glaucoma. Why Glaucoma and not cataract surgery for instance? I’m tired and beaten up, but I’m neither a hero nor a coward, not a sentient nor an idiot;  I don’t need to be a seer, some kind of morbid Karnac the OK, to know the outcome for either cataract or Glaucoma. I’m declaring right up front what is going to happen, how it will affect my patients, my staff, and me, and what the ramifications will be for American healthcare. I’m surrendering in Glaucoma because I can, continuing to fight in cataract surgery because I must.

In my 27 years as a physician only one paperwork/government regulation/billing issue has ever resulted in better care of my patients: the requirement to do an extended Review of Systems for a particular kind of visit resulted in the identification of major side effects from glaucoma eyedrops. Indeed, this was a total surprise and led to a rapid change in the way we took care of Glaucoma patients. Older medications, effective or not, were replaced by newer medications or laser because the newer treatments were both more effective and freer of side effects. What will I find this time?

Timoptic (topical Timolol) was introduced in the early 1980’s. It was a Godsend. Nothing less than a miraculous savior of vision, keeping legions of patients out of the operating room and saving thousands and thousands of people from certain blindness. It’s been off patent for decades but is now no more than a third line treatment. Why? Tons of side effects, some subtle (decreased exercise capacity, erectile dysfunction) and others less so (my friend essentially killed his very first Gaucoma patient in year one of the Timoptic era by prescribing Timoptic and causing 1st degree heart block). It’s really cheap now, but who can write this Rx and look themselves in the mirror, white flag or not?

We know that the Lipid class of Glaucoma eye drops is the most effective group of pressure lowering medications. The original, Xalatan, dethroned Timoptic in less than 2 years. Lower eye pressure and no systemic side effects and a new treatment paradigm was nigh. The worst side effect was a permanent darkening of the iris in 9% of patients, the price to pay to save your vision. Xalatan is now available as a generic (latanaprost). There are 3 newer, stronger, more effective Lipid medications, all of which are branded and all of which are 2-4X the cost of latanaprost. They all reduce eye pressure on average 2-3 points more than latanaprost.

I’ll start here. Starting next week every new glaucoma patient who opts for medical treatment will start on latanaprost. On top of that I will change every patient on a branded lipid to latanaprost if they risk losing insurance coverage for their drop. I will not respond to any insurance company challenge. If pressure reduction is inadequate I will follow my standard protocol and I will offer a second medication or glaucoma laser treatment, both of which are standard of care. If a second medication is chosen I will write for the generic second line Rx, an alpha-agonist. The generic and the brand alpha-agonist have equal efficacy; the generic has a 35-40% unacceptable side effect rate compared with the brand’s 10-12%. The generic cost is ~1/4 of the brand.

My staff and I will take the time necessary to inform my patients of these side effect issues, a time investment that will be a laughably small fraction of the time it takes us to fight the paperwork wars for Brand coverage. I will document this up the wazoo, noting every treatment failure and every last little side effect, jotting down every incidence of patient non-adherence. I will gear up for more glaucoma surgery, both laser and incisional, because I remember how much more of both I did in the days when Timoptic was king, in the days when version 1.0 of today’s medicines was so hard to take due to side effects. I will have this all on hand when we start to read of the new golden age of Glaucoma surgery.

I will be ready to answer the critics who accuse eye doctors of doing too much Glaucoma surgery.

8:00 p.m. on a Friday night. An urgent page from Express Scripts. “Approval needed for sleeping medicine, Agnes Jones*. 800–333–4444.” Agnes Jones is a nursing home patient with a brain tumor.

4:59 PM, Friday afternoon. Telephone call from CVS pharmacy. “The nonsteroidal anti-inflammatory eyedrop that you prescribed is not covered by Mrs. Jones’ insurance company. We need your authorization to change to the generic version.” We told Mrs. Jones in writing that the generic version was inferior, caused pain, and had 10 times the complication rate. On Monday.

7:30 AM, Sunday morning. Telephone call from answering service. “Doctor, the prescription that you sent electronically on Tuesday for Mrs. Jones was written incorrectly. Please correct this and refile it immediately. Please remember that your status as a provider is contingent upon meeting our customer service standards.” Confirmation of receipt/prescription filled was received on Wednesday.

And, my very favorite, most recent telephone call, this one from the daughter of one of my patients. “Dr. White, NALC needs you to send them a letter proving that my father’s eye drops are not prescribed for cosmetic purposes.”

Welcome to the world of the American physician in the modern era. There are, of course, a host of entirely appropriate responses to all of these pages, beeps, and phone calls. However, this last one put me over the edge. I sat at my desk with the message in front of me, closed my eyes, and thought about how I’d REALLY like to respond. The totally, truly amazing part about this request to justify the eyedrop prescription was that, not only was all the information necessary to cover this already on file at NALC, and not only did a real, live human being actually look at this file, but she admitted that and gave me her name! Ya can’t make this stuff up.

“Dear Alex:

Thank you for this opportunity to express my thoughts about some of the pitfalls associated with the pending ‘meaningful use’ regulations for computerized health records. After you personally reviewing the record you requested information about eyedrops that I prescribed for one of my patients. There is apparently a concern about whether or not this patient is using said medication for cosmetic rather than medicinal purposes. As you know, among the more significant ‘meaningful uses’ of electronic medical records are to make sure that everyone has the same exact information about a particular patient, to utilize this information in such a way that proper care is ensured, and to be more time-efficient for the patient, doctor, and everyone else involved in the care process.

If you will open up your file again regarding the patient in question, JOSEPH Smith, you’ll see that, had meaningful use activity actually been applied, this entire communication could have been avoided. Had you actually read the file you would have seen that MISTER  Smith is an 87 YEAR OLD MALE with a long-standing diagnosis of GLAUCOMA. As your software no doubt shows, the eyedrop Lumigan  is a first line medical treatment for glaucoma. All of this information is contained in your database since Mr. Smith has been taking this medication for no fewer than five years, and the bill for his office visit was paid in full by NALC, diagnosis: glaucoma.

A copy of this letter will be forwarded to my US Rep. and two senators, the FDA, and CMS along with a note asking how they propose that all of their fancy new laws about EMR and ‘meaningful use’ will prevent lazy and incompetent file clerks from blinding my patients.

I trust that the information in this ‘old–school’ letter is meaningful enough to prove that Mr. Smith’s use of Lumigan is not for cosmetic purposes.

Sincerely,”

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“Dear Alex,

Attachment: Pic.JSmith.jpg

Seriously? Really? You would like me to prove that my toothless, 87-year-old patient named JOSEPH is not using his glaucoma drops for cosmetic purposes?! The guy with the electronic bill in your system with a diagnosis for glaucoma, taking three other glaucoma medicines, all for 20 years? The Joseph Smith who can’t be bothered to remove the 11 skin cancers growing out of his face like barnacles on a sun-scorched barge? COSMETIC?

This is a joke, right?

Sincerely,”

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” Dear Alex,

You caught me! But please, don’t tell anyone else. We have the largest population of semi retired 87-year-old drag queens in America in our practice. They just can’t let it go! We have been prescribing medicines so that they could maintain their long, luxurious eyelashes forEVER. I mean, who WOULDN’T rather have long, thick, natural lashes, especially after a lifetime fussing with those falsies and all that icky, sticky glue. Joe has been SO happy!

It’s amazing how important it is for him and all the ‘girls’ to be able to bat their eyelashes at those cute boy orderlies in the nursing home.

Not that there’s anything wrong with that…

Sincerely,”

Sigh…

*All names are fictitious, of course. The examples are not.