Prescribing

By Harold I. Eist, M.D.
APA President

I was called by a pharmacist the other day and informed that the dose of medication I had prescribed my patient was incorrect. I responded, "I appreciate calls from pharmacists when they are checking with me to assure, if they have questions, that this is the dose I had indeed intended." I have frequently had this experience over the years and have been gratified by what I felt was the concerned behavior of a professional who is part of the treatment team. This was different. It was not collegial; it was rude.

I indicated to the pharmacist that this was the dose the patient needed and to go ahead and fill the prescription. The pharmacist insisted that the dose was higher than that listed in the PDR and if I did not lower it, I would be reported to the DEA. Of course, I called the pharmacist's supervisor. The supervisor apologized and said that he would talk with the pharmacist. This transaction was unfortunately symptomatic of what is happening systemwide in medicine. Managed care organizations are limiting formularies, insisting they will provide only generics, and they are even insisting on the dosages that will be allowed. Even when psychiatrists insist on nongenerics, the managed care organization instructs the pharmacist not to fill the prescription until the physician either fills out a form or writes a letter documenting the need for a nongeneric. This process may take weeks and is patently illegal. It puts patients at risk and increases costs. Patients may be able to get the nongeneric or nonformulary medication, but they may have to pay for all of it out of pocket or the difference between the generic and the nongeneric--a significant penalty for insisting on the right treatment.

But this should be no surprise. Managed care companies have been prescribing and limiting the dose of psychotherapy for years. Why not medications? If they can get away with one, why not the other? If clerks are to decide what treatment patients receive, why not pharmacists? If we silently endure this abuse of our patients and the treatment situation, why should anyone, let alone our pharmacist colleagues, respect us?

All of these activities are harmful intrusions into the practice of medicine because, at bottom, they attack the doctor/patient relationship, undermine confidence in it, and lead, ultimately, to inferior care. While the bottom-liners are attempting to dictate dose, they are also deciding on the quantity of medication that can be dispensed. Some plans limit prescriptions to 21-day supplies, others to 30-day supplies, removing this decision from the doctor and patient. This inflexibility adds to costs and often inconvenience and, again, communicates lack of respect for both doctor and patient. More important, it establishes price as the preeminent value in medical treatment.

A further egregious intrusion into patient care is the economically compelled requirement of writing three-month prescriptions of potentially lethal substances, primarily to increase managed care company profits. This has created great risk for patients and their families. Even when we oppose this practice, our financially strapped patients pressure us to give them the larger supplies. The parents of a suicidal teenager pleaded with me to give them a three-month supply of medication. Finally, I agreed, if they got a strongbox, kept it locked, and slept with the key around one or the other of their necks. They agreed to these conditions, brought the strongbox into my office, and showed it to me. One of the teenager's parents was dispensing medications at their home when the phone rang. The parent went to answer the phone, leaving the strongbox open. The teenager took a lethal dose of medication and almost died.

Mail-order prescriptions also attack the linkage between the physician, the neighborhood pharmacist, and the family. The pharmacist comes to know the patient, the patient's medical and medication history, and the physician and his style of practice, and thus becomes part of the treatment team. The pharmacist, being part of the treatment team, expands the patient's medical safety net.

I am now encountering a plethora of new forms requiring me to justify why I am prescribing what I am prescribing and to obtain "precertification" to prescribe certain medications. This is another hassle factor that increases real costs, frustration, and irritation and delays care. If I prescribe a new or relatively new agent because my patient has not been helped by the previously available medication, I have been informed, through the pharmacist, that the insurance company won't pay for the new medication and I should prescribe something else that has already proven to be ineffective.

In the face of all this, a pharmaceutical representative came to see me and gave me "new prescribing information" on the medication she was promoting. I said, "You know, pharmaceutical companies should not indicate only usual and customary dosage ranges in their literature." She answered, "I think the FDA requires this." I responded, "The FDA cannot prevent you from putting an asterisk on your literature, stating that dosages might vary beyond the parameters listed, on the basis of an individual patient's needs."

Guess what? I have written to every pharmaceutical house producing psychotropics requesting they do just this and to the AMA and every other medical specialty society to get them all to join us in this patient care initiative. We have to be out front in denouncing practices that endanger lives.

(Psychiatric News, September 20, 1996)