Monday, September 24, 2012

I Do Solemnly Swear

In Maryland, there is a tiered formulary for Medicaid patients.  What this means is that the physician must try a first tier medication before a second tier medication.  What makes a medication a tier one medicine? The cost.  Some medicines are more expensive than others, and beside that, the state contracts with pharmaceutical companies for special rates.  So in Maryland, if you want to prescribe risperdone, it's not a problem.  If you want to prescribe some of the other atypical antipsychotic medications, you need to fill out a prior authorization form giving the diagnosis, the target symptoms, the name of the medicine, the dose, strength, frequency, and quantity.  The doc needs to check off whether it's being continued from an inpatient setting, if there is a condition or drug interaction which prevents use of a preferred (i.e., cheaper) medication, s/he must list other medications that have been tried with their strength, frequency, dates of use, "compliance (at least 6 days/wk)" and reason for discontinuation.  Oh and the demographics of all involved including the doc's NPI number, specialty, address, fax, email, phone, and the patient's name, DOB, address, Medicaid number and height and weight and gender.  Just a simple little form.

Finally, at the bottom of the form, the prescriber must sign off on the following statement, "I certify that the benefits of antipsychotic treatment for this patient outweigh the risks."  So like how does anyone know that before the patient even takes the pill?  Risk benefit is an individual issue and depends on  a balance of side effects and response to a medication.  Until the pill is swallowed (and perhaps until quite a few pills are swallowed), we don't know if the patient will have side effects, or if the patient's symptoms will even respond.  Mind you, if the patient doesn't respond to the initial dose and we to raise it, the doctor needs to fill the form out all over.  I think the state needs fortune tellers, not doctors. 


Sarebear said...

Yeah, it's a pain in the neck. The first time we needed to do this, the doctor's office didn't know, so at the pharmacy the pharmacist tells us, we call the doc's office and she fills it out, but I have to spend 30 mins going in, 30 mins coming back, just to sign the dang thing, a day after I already drove the hour for there and back. Pain in the neck.

A couple months ago, we lowered the Vyvanse dose; that needed a new verification. Oh, when the 70mg dose was a year old, that needed a new verification to renew the verification. I'm at 40mg, man o man no wonder i was ridiculously amped on 70. Why didn't I figure that out for a few years lol?

Anyway. I've never had a verification needed for the antipsychotics, like risperdal, depakote, geodon, lamictal, seroquel . . .

Not for Topamax either, that's off-label use isn't it?

Didn't need verification for Zoloft either.

It was annoying that while on regular insurance AND Medicaid, I had to pay up to $70 for some meds a month, multiply that by several; we couldn't apply both the ins. and Medicaid because in order for the meds to count against the $5k deductible, it wouldn't let us do both. (we had a HSA and once deductible met, everything paid 100% which came in handy for my two surgeries $35k each, even without those the $5k a year which included scrips saved us money, even without scrips it was on the edge, or paying more for the scrips wouldn't have made any sense.)

I don't think I needed a verification for clonazepam or lorazepam, either.

I can see a list online of this stuff, there were some things that surprised me and some that didn't.

Psych meds and expensive heart/cholesteral meds seemed to make up a big portion of the list, though.

I'm basing my assumption that some of my meds didn't need verification on the fact that the one that did needed my signature.

(Oh and then there's talking to my GP about the state EHR I'm being forced to opt in on since I'm on public assistance and after talking to him I'm not sure he understands what it is. Then again maybe I don't either.)

Simple Citizen said...

Psychiatrist, Psychologist, Psychic, Psycho,
- they're all the same right?

(I'm guessing the mean "potential benefit and potential risks")

Anonymous said...

I don't really get the issue since shrinks convince patients to take meds by saying the benefits outweigh the risks. I have been given about every thing out there and while I have been warned sometimes about possible ill effects, all the doctors ever said was take this so you don't die today. They worry much less about the chance you might die in a year or five.

Anonymous said...

Yep. And think about how great it is for the patient, when the pharmacy tells you they couldn't fill your prescription when you come to pick it up at 7:30 at night because your insurance is insisting on something different and your psychiatrist's not reachable to call in something different because it's late evening. Can't count the number of times that's happened to me. Thankfully my current psychiatrist considers that a very valid reason to call her up at 9:30 at night and has never complained about prescription insurance hassles (and she is private practice. No insurance.) Certainly not all over the web. If I was a patient who saw you and read this, I'd feel very reluctant to have to fill any new prescriptions since it is clearly such a hassle for you.

End of the day, it's paperwork. And you're getting paid for filling it out.

Dinah said...

Anon: if the medicines work and the side effects are non-existent or tolerable, then the benefit may well outweigh the risk.

I think Simple Citizen has it here: If the form said "I certify that the potential benefits outweigh the risks" I would be fine with it.

Clink's interpretation of this form is that it really means "I certify that I am not an idiot"

I realize the bigger issue here is for the patient who may show up to get their medicine only to discover it's not there.

Anon: Of course it's paperwork and I do it, I just wish it made sense and I wasn't asked to "certify" and sign something that I can't be sure is true until I see how the patient responds. These are for Medicaid and I am paid by the clinic for the time. In private practice with private insurance, these forms are often more detailed and take 20-30 minutes to deal with (they involve phone contact with the insurance company) and generally happen after the patient leaves and are not on time that physicians are being compensated for.

Katie said...
This comment has been removed by the author.
Anonymous said...

Dinah: In private practice you are being paid a fee. That fee includes necessary paperwork that you do otherwise. Just like it includes necessary thought you do outside of the 45 minutes per week you spend with the patient. Just like a teacher is paid a salary for preparing outside of the 6.5 hours a day spent with children, an internist is paid a salary that does not cover only the 31.8 minutes spent with patients, and lawyers are paid a salary that certainly includes time outside of the 9-5 hours. There are therapists who insist on doing paperwork in session or charging for it. That is your right. However, it also clarifies for the patient that your priority is financial.

Anonymous said...

Charge for completing the form. You wouldnt be the first doc to tack a $25 charge for forms onto a bill.

As for the certification - It sounds more like it is asking "are you sure this patient needs this med" as in are they sick enough to justify the med and have you considered options and meds that may have few side effects or lasting impact or cost.

Some of these meds are heavy hitters and dont come without real long term costs to the patient - such as the atypicals - the question is asking - is this patient so sick that it is worth the high risk of diabetes with this med, will this med improve their quality of life more than the diabetes will reduce their quality of life?

For some patients it is easy to see that the benefit outweighs the risk (diabetes vs death, diabetes vs homeless, diabetes vs jail = easy choices / diabetes vs depression, diabetes vs increase intensive therapy = not easy choices / diabetes vs sleeping pills to sleep = simple choice)

You can not predict the future but as a doctor you should have a solid understanding of the general impact meds will have on a given patient.