A Prescription Error, A Relationship Preserved

The refill request was for a muscle relaxant, one with significant potential for addiction. I opened the patient’s chart to see when it has last been filled. I had approved a refill 25 days prior. This request was 5 days early.

Early requests are not entirely unusual, as patients are often afraid that waiting to the last minute can result in them running out of medications. A pattern of early refills can indicate a problem so I decided to log into the state controlled substance database to view the patient’s prescription history. It seemed that he had consistently been filling the medications 3-5 days ahead of the due date. I decided to investigate further.

I scrolled back through the online history and saw something that made my heart sink. The database showed that 2 months earlier the patient had filled the medication at two different pharmacies one day apart. If this was true, the patient was abusing the medication.

I could not believe it. This patient was one of my favorites, our interactions had been consistently enjoyable, often with interesting conversation. (He is a passionate and hard working man and we have much in common.) The thought that he might have been abusing his medication, that I might be forced to confront him and possibly dismiss him from the practice filled me with dread. Unfortunately, the evidence on my computer screen was hard to ignore.

I called my receptionist over and asked her to call each of the pharmacies to confirm that they had indeed filled the medications on the dates indicated. A few minutes later she handed me a note. Both pharmacies had confirmed the refills.

I wondered how to address this with the patient. The evidence was pretty clear but something just didn't feel right. I wondered if my unease was more about the possibility that I had been deceived than it was about the patient’s circumstance. I decided that I did not need to be confrontational immediately, that I would give the patient a chance to explain.

I called him on the phone and he answered immediately. “I received your refill request,” I told him, “but it was a few days early.” I went on, “ So I checked the state database to review your history, and according to them, you refilled the medication twice in January only a day apart, on the 16th and 17th.”

“Doc, there’s no way. I didn’t get two prescriptions. Let me call the pharmacies!” He was adamant, yet not defensive. I told him that I would not be able to fill the medications without him coming to the office, as we would have to address the issue and I would need to document it in the record. As much as I wanted to trust him it would be a mistake to assume that the pharmacies were at fault. I told him he would need to sign a controlled substance agreement and that his practice of using different pharmacies based on his work schedule would need to end.

He did not argue at all. “Of course, I understand. I will come in tomorrow!”

I received a text from him within a few minutes, saying he had just called and only one of the pharmacies had confirmed a refill. The state database must be wrong.

I decided to call the pharmacies myself. The first pharmacist came on the line right away and looked up the patient’s medication history. She read off the record for the date in question. “We show a prescription on January 26th that was deleted. The patient never received the medication.”

I was so relieved! The patient had been telling the truth! (When it comes to controlled medications this does not often happen.) I called the patient back and gave him the news. I told him I could refill his medications but that it would need to be on the due date, that I could not refill the medications early. He was in total agreement.

When I hung up the phone I breathed a sigh of relief. I had dodged a bullet. There was a time not so long ago when I would have assumed the worst and been more confrontational. If I had done that, a relationship might have been lost. Giving him the benefit of the doubt had made all the difference.


Drug Secrets Your Doctor May Not Know

The patient was angry. His pain management doctor had written a prescription for a new pain medication and the patient expected it to be covered by his insurance. It wasn't, and the patient was stunned by the drugs $320 price tag. There was no way he could afford the drug and he went home empty handed and in pain. 

Stories such as this are not at all uncommon. Prescription coverage varies widely from one insurance to the next and seems to change daily. It is impossible to keep current. Previously covered and once inexpensive generic medications become uncovered and expensive seemingly overnight.

A week ago I wrote a prescription for doxycycline, a 48 year-old antibiotic that  a few years ago had a cash price of $4 at Target and Wal-Mart.  Imagine my surprise when the pharmacy called saying it was not covered by insurance and the cash price was now $65! How does that happen?

A few months ago a patient called asking for help with his sleep medication. His insurance would not cover generic Ambien and he could not afford the $85 his pharmacy charged for 30 pills. I had my staff check on what our cost would be if we ordered it ourselves. Our price- 100 pills for $3.10. The pharmacy was charging $85 for a medication that cost them $1!

100 mg Viagra tablets cost almost $30. Five 20 milligram tablets of the same drug from the same manufacturer, sold under the brand name Revatio, can be purchased for $4. When I asked the drug company salesman why this was he could not provide me with an answer.

There are many aspects of medical practice that are frustrating but medication costs and coverage are of particular concern. New drugs are always ridiculously expensive, with thirty day supplies of new medications consistently above $150. The prices are often concealed from doctors by sales people whose presentations focus on co-payments and discount cards instead of total costs. 

What can patients do to navigate such a system? I am often confused and perplexed by insurance coverage of medications, how can a lay person be expected to know what to do? We are in desperate need of greater transparency in how medications are priced.

While we wait for that day to come here are a few recommendations-

1- Tell your doctor when a medication is expensive. There may be less expensive alternatives. My daughter was once prescribed a medication that cost $700 a month. The doctor was shocked to learn of the cost and changed to a more affordable option.

2- Shop around. Prices can vary widely from pharmacy to pharmacy. A few years ago I called several pharmacies to check their price for generic Prozac. The four prices were, $7, $11, $25 and $40 for a one month supply. Do not feel as if you do not have choices.

3- Ask for an inexpensive drug. For common conditions such as high blood pressure, diabetes and sinus infections there are usually very inexpensive options. Target and Wal-Mart sell a 30 day supply of many common generics for $4.

4- Use coupons. Web sites such as goodrx.com can offer sizable savings. Almost every brand name medication will have coupons on their websites.

5- Fight when needed. I recently had a patient who was taking a medication twice a day for chronic pain. It worked well but wore off in the middle of the day. I gave him a sample and suggested he try taking the medication three times a day. He was thrilled to report dramatic improvement so I sent the new instructions to the pharmacy. His insurance denied the claim saying they would only cover the medication twice a day. I wrote two letters and personally called the insurance but they did not budge. He appealed the denial all the way up to the California Board of Managed Care. The Board notified him yesterday that his insurance would be required to pay for the medication. It took more effort than it should have, but he won!

- Bart

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