I had a patient with non-valvular atrial flutter denied dabigatran (Pradaxa®) by their insurer recently. The patient had diabetes, hypertension and has had a heck of a time maintaining therapeutic blood thinning levels (prothrombin times).
But those are the rules, you see. Only patients with non-rheumatic atrial fibrillation can get dabigatran, I was told. Dabigatran was never approved for atrial flutter, only atrial fibrillation. Never mind the stroke risk in non-rheumatic atrial flutter, like atrial fibrillation, has been found to be significant.
For my patient, dabigatran would have been the perfect solution.
But increasingly I'm finding the patient is not mine, they're someone else's. Someone else who tells me their rules - someone who has little to no responsibility for the patient, outside of their accounts receivable. Oh sure, I suppose my patient could pay for the drug themself if the drug weren't so horribly expensive, but shouldn't the judgement of a person ultimately responsible for a patient's well-being be trusted to decide the best therapy for a patient? Evidently not. Doctors, as we continuously hear time and time again in the media and will our politically correct health care reformers, are the problem with costs in health care and costs, above all else, must be reigned in.
So we return, my patient and me, to warfarin and subtherapeutic and supratherapeutic INR's with their increased risks of stroke and bleeding because those in charge tell me they know better.
Short term savings with long term implications, because I'm no longer allowed to think in the world of Paint-by-Numbers medicine.
This is what happens when doctors are excluded from the health care playbook.