Sunday, November 27, 2005

As a resident, I was taught to be careful in my prescribing habits. Be careful not to prescribe too many meds to one patient; be careful not to prescribe a med to treat the side effect of another med unless the first med was critical; attempt to stop one med for each new med started. We all know that the risk of adverse reactions or drug-drug interactions increases greatly if more than 5 meds are used.

As an ER doc and a hospitalist, I often see patients who are on greater than 10 meds. When I look at the lists, I frequently see redundant meds or contraindicated combinations. It is not uncommon to see meds used to treat symptoms created by other meds.

Unfortunately, I can't do much about it. Sometimes I can call the PMD and, gently, suggest alternative regimens, but it is difficult, almost impossible, to educate the patient directly. The patient has only just met me and his PMD has been treating him for years. Of course the PMD knows better, right?

Here in Tennessee, we have seen that our TennCare population uses a far greater number of prescription meds than in any other state. Many of those patients have now been dropped from TennCare and many of the remaining beneficiaries have been limited to 5 prescriptions a month. Of those 5, only 2 can be trade-name. This includes short term prescriptions. So a prescription for two or three days of a pain med may mean no coverage for a chronic drug.

Not that this is so bad. It requires the physician and the patient to manage the patient's regimen more specifically. In the ER, when I write a prescription for an analgesic, I can write for something inexpensive and recommend to the patient that they pay for it themselves, as opposed to using TennCare.

Here is a story about a doc trying to do the right thing.
Dr. Jei Martin is Moore's doctor. Martin says when Moore first came in her office she was on 34 medications all paid for by TennCare. Dr. Martin says she needs a blood thinner to prevent a stroke, but not 34 or even 17 prescriptions.

“I think the whole system failed in that respect the whole system failed,” said Dr. Martin.

Dr. Martin says the system failed taxpayers, and it failed Jennifer Moore, who was clearly overmedicated. Dr. Martin was reducing Moore's medications slowly. Then TennCare cuts sped things up.