Tuesday, September 27, 2011

When Doctors Are Excluded From the Playbook

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.



Jay said...

If you can't beat 'em, join 'em.

I'm sure her insurance would be glad to pay for a 24 hour Holter. You could then scrutinize for any evidence of a fib (which almost always turns up if you look hard enough).

New diagnosis. Problem solved.

Matthew Bowdish MD said...

Not surprisingly, we have the same problem in allergy/immunology. One insurer recently moved us to a 'non-preferred' provider status, because among the various medications we use for asthma is omalizumb, a monoclonal antibody directed against IgE approved for moderate to severe asthma. And we’re hardly putting every patients on this admittedly expensive drug. Accordingly, by doing a good job for our patients our charge per patients is slightly higher on average than practices that don’t use omalizumb. Never mind that people still die from asthma exacerbations…The insurer has made the decision that they would rather reward doctors for suboptimally-treating their patients than pay to keep their patients healthy. So when I see health care CEOs on KevinMD wax poetic about how awesome it is to follow mandated 'guidelines,' or the president claim the “blue pill” is just as good as the “red pill” (or is it vice-versa?), excuse me if I disdainfully ask where they earned their medical degrees.

DrWes said...


More testing, more costs. So much for savings, eh?

No wonder we're the problem.

Jay said...


Don't let my flip attitude in the post deceive.

I agree that performing additional testing to appease the insurance companies is ridiculous. If that's what it takes, though, I'll do it. It beats the alternatives.

Yours is a higher mission. By bringing this nonsense into the public realm, you hope to effect some changes to this crazy system.

I just hope, in the end, you don't let the system beat you. Your patients are counting on you to do what's right.


Lisa said...

It is sad and frustrating that our doctors can't make the decisions regarding our healthcare. The same insurance company that made my doctor send me home three days after major surgery sends me message that say "You have these conditions. You should contact this kind of specialist." I shake my head in confusion over this. First off, I don't have all the conditions they say I have. Most of them I was tested for and it was ruled out. And second, the conditions on the list that I do have are being well controlled with my primary care physician. How is it saving them any money if I now go to a specialist? And then, like you pointed out, they are telling that specialist what he can and can't do to treat me. I wish there was a way doctors and patients could take back control of their health care. But without the insurance company, I could not afford the care I need. And if patients can't pay for their care, doctors won't have a job. There simply has to be a better way.

Anonymous said...

I am certain you are a diligent and smart doc. Since I am neither, I defer to you, but would gently ask -
If the "number needed to treat to prevent one (nonhemorrhagic) stroke with dabigatran (150 mg twice daily) is 357" is this therapy appropriate for many patients?

How do you control skyrocketing costs, a few $ per month v $350 (approx) if the payback is really that low?

Am I missing something?

Keith said...

Correct me if I am wrong, but the insurer is not saying you can't use the medication; just that they will not pay for it. So this is an insurance issue; not one of commanding that we can only treat according to what insurance dictates.

From a practical standpoint, I realize that this may mean that the patient cannot afford the medication, but this speaks more to the high cost of newly developed drugs, and that when pharmaceutical companies hit on a winner, they milk it for all it is worth. Remember, the pharmaceutical industry is the most profitable industry in the world as measured by their return on investment.

I would think a large measure of blame here is with the maker of Pradaxa, who has priced this unrealistically on the open market. Thank goodness for our competitive insurance market for pharmaceuticals that has kept priceses low (except for those without competition) and bloated our deficit (thanks to all those generous republicans that once thought unfunded mandates were a good thing). Only thing left for insurance to do since they have no constraint on price is to limit the use of the drug by restricting it to only its FDA approved indication!

Anonymous said...

Perhaps they think TEE followed by flutter ablation w lovenox bridge and at least 1 month of coumadin would be cheaper.

ERDoc said...

I'm with Keith.

There is no one saying you can't prescribe it, just that the insurance wont pay for it. At some point people have to make a choice to pay for (some of) their own health care

Anonymous said...

Greatnews! They have made me king! Let it be known that as of today there is no Obamacare, no Medicare, no Medicaid and no insurance companies, no mandates, no more regs, no more FDA. Medical care will be between the doc and the patient. Charge what you will, doc. Patient, pay what you can. Hospitals - collect directly from the patient. There. That's taken care of. Everybody happy?

DrWes said...

Anony 02:09 -

If the "number needed to treat to prevent one (nonhemorrhagic) stroke with dabigatran (150 mg twice daily) is 357" is this therapy appropriate for many patients?

How do you control skyrocketing costs, a few $ per month v $350 (approx) if the payback is really that low?

Don't forget to factor in the costs of INR's, lost time from work, etc. with warfarin into that cost/benefit analysis. If you do, the difference between warfarin at "a few $ per month" v $350 per month might not be that different. Oh sure, drug companies want to make a profit and charge tons of money, but they also took the risk to develop the medication. Don't forget prior attempts to create ximelagatran (a fore-runner of dabigatran) resulted in over a $1 billion dollar LOSS to the company that was first out-of-the-gate with this class of medications.

Further, stroke is hugely expensive to our health care system AND to the patient and their family (if they survive). We can usually give blood if someone bleeds, but it's not so easy if a patient suffers a stroke.

When people's risk of stroke is low, the the cost of the med might not be warranted. But if the risk of stroke is high, there should be a more compelling reason to justify the cost of these meds.

But it is important to realize that doctors never have the opportunity to look backward in time for an individual patient: it's always about the future. Like spinning a barrel that has lots of holes and then pulling the trigger - you just hope you've made the right choice to limit the chances your patient will suffer ANY problem with this disorder.

Tim Hulsey, MD said...

Keith said, "but the insurer is not saying you can't use the medication; just that they will not pay for it."
In reality the insurance company has, de facto, made the patients decision for him! Wes can explain to them the reasons for using the drug for this patient, but the insurance company has RULES! Stroke patients can live for decades in a vegetative state with 24 hour a day care. How much does that cost compared to Wes being able to do what's best for his patient?
Anonymous said, "Greatnews! They have made me king!"
Had you been made so a hundred years ago and done the same thing, health care today would be cheaper. What doctors and hospitals could charge would be determined by competition. Health insurance, including Medicare, trundled along for years floating prices higher artificially when times were good for them. Now it's come to the nut cuttin' and the lack of a free market in health care has buggered the system.

Anonymous said...

Dr. Hulsey,

Of course. Neither technology nor miracle drugs nor marketing nor "the" market have anything to do with health costs, notwithstanding Dr. Wes' argument regarding the reason for the cost of new drug he wishes to prescribe.

And I am intrigued by your "floating prices higher artifically", but why argue? I have just proclaimed an absolutely free market. Please let me know how it works out for you, your hospital and your patient. Make it quick though. My ticker isn't too healthy and I can't afford that operation my doc thinks would be best.

Tim Hulsey, MD said...

Anonymous said, "My ticker isn't too healthy and I can't afford that operation my doc thinks would be best."
Lack of cerebral blood flow is often contemporaneous with delusions.

Robert C.,MD said...

Dr. Bowdish,

Is there any evidence that omalizumb saves lives?...good evidence, randomized trials?