Does Your Doctor Refill Prescriptions by Phone?

This blog was a little surprising after my two blogs on prescription errors, but we can always learn more. Yes, most doctors will not issue prescription over the phone and here are some instances when a doctor will not refill the requested medicine:

• One of his/her partner’s patients calls after hours for a refill on narcotics - they can become adictive.
• A patient wants a refill beyond his/her expertise. He/she won’t be refilling your cardiac medicines as this should be done by the prescribing physician for several self-evident reasons.
• He/she hasn't seen the patient recently.

Most doctors hesitate for valid reasons for wanting to see a patient before issuing a prescription(s). The author lists these six reasons:

1. Does this specific drug still make sense?
2. Can the dosage be lowered?
3. Have any new symptoms developed that might require diagnostic investigation? Suppose the patient has been losing weight, for example? What if the heartburn has worsened and a new disease is responsible?
4. Is the patient experiencing side effects from the medicine that he or his primary care physician might not appreciate?
5. Could the heartburn medicine interfere with new drugs that the patient is now taking?
6. Is the patient up to date on other issues within a gastroenterologist’s responsibility such as colon cancer screening?

Refilling routine medicines may not be routine and should be done with care and caution. The author uses this example - a patient from 2 years back who has GERD might think he needs Nexium for his heartburn. What if his symptom is actually angina? Get my point?

The author says, when we ask you to stop in for a brief visit, it’s not because we delight in hassling you or are hungry for your co-pay. We’re trying to protect you and to keep you well. Doesn’t this seem like the right prescription?

Some prescriptions can be written without seeing the patient if the patients keeps regular appointments. I have had this happen quite often. This is because I have been seeing the doctor almost quarterly for over 14 years and have always been up front with him. I needed some heavy duty pain killers, and for that he wanted to see me which I had no problems with this because my research had told me this would be necessary as the medication would be a narcotic and they don't like prescribing those. After doing an examination and another doctor had done a few tests, I was able to get my prescription and several refills.

When I asked that the strength be reduced about two months later, he did, but told me I would need to see him before any more refills. Since I would have an appointment two weeks later, I reminded him of that and he said he would prescribe enough to get me to that appointment. By my appointment, I was out and told the doctor I did not need any more as the pain had subsided a few days before. I am happy that I have not had any further pain and even the doctor is happy that I don't need the medicine.

October Meeting with Our New Members

We knew that our meeting was going to be different, but how different we did not know until our meeting started. Even Tim was caught off guard. Sue and her husband were absent because Sue's mother had passed. However, the number of new members more than made up the difference. We had expected six new members, but were in shock when 14 people showed up.

Jerry said that four were others that he had unable to contract for our prior meeting with the nutritionist, and four of the six had brought another person with type 2 diabetes. After introductions, Tim asked each of the potential new members to think of a nickname to use. Tim then explained that we use the nicknames to keep tabs on each other and allow them to talk to other members without letting others around them know whom they are talking about.

Then Tim opened it up for questions from the new members. Most wanted to know how often we meet. Barry told them that this varies. We try to meet once a month, but this can be upset by other events. Barry continued that we normally do not have meetings in June, July, and August. However, this year, we had two meetings in August, but not for everyone. We had two meetings in September and now two meetings in October. In addition to our November meeting, several will be making a presentation to another group.

Jerry spoke up then and said two of the meetings were for him and those seeing his dietitian wife. He continued that they take things as they happen and try to make the most out of events. He said if they need three meetings to accomplish something, they will have three meetings. Tim said that is right. Sometimes it is only five or more people that can have a special meeting, but we have one meeting per month for everyone. Brenda said this happens because we are not secretive about our diabetes and different numbers of us can be working on different projects.

Allen said that this happened this year as we had three meetings on interventions to help us know how to help other people with type 2 diabetes. James said that he was the subject on one intervention, but not by this group, but during a meeting of several groups. Tim said Jerry was an intervention project of several of the members and those that Jerry was able to contact were brought to a meeting not requiring an intervention.

The next question was about membership and would we be limiting membership. Jason spoke and said this is something I think all of us have thought about. At one time, we were at almost 20 members, but because we like our somewhat informal nature, a few split off from our group. Greg is the leader of that group now. They wanted formal officers, meetings on a specific day each month, and other set rules.

Tim said that he was elected as group leader, Barry was program chairperson, and A.J is group historian. We don't have a treasurer because we don't collect dues and or other officers because we don't need them. Two of us send out meeting summaries after each meeting, with one waiting until the other has sent out an email and then that person adds other points if necessary. Bob generally blogs about our meetings so we have several reminders of what transpired. This way if someone needs to miss a meeting, they don't feel like they were left out.

Tim stopped then, and said for all those new people present, to be sure he had their email address and telephone number given to him. Email addresses for meeting notices and summaries. The phone numbers in case they were needed for something special. He stated that all those new to the group would be sent the email addresses and phone numbers for the rest of the members.

The meeting continued for another hour with more questions from the new members and some from our group. Max said we have a question that needs a vote or thought until the next meeting. Tim said yes, do we want to limit members or add more members. The group agreed that for the present, we would not limit membership, but would take up the question again when we were near 45 members. Everyone present did want to become members. The vote was unanimous and we went from 17 to 31 members that quickly.

A couple of the new members asked if they could attend the meeting when we presented the program. Tim asked if they knew the place and the one answered that he had grown up there. Tim said he would ask and let them know if they had room for visitors. This brought several more requests and Tim took the count (9 wanted to go) and said he wanted emails to be able to contact everyone. This ended the meeting and Tim collected email addresses and phone numbers.

Additional Information on USPSTF Pronouncement

On October 21, I received an email from the ADA promoting the US Preventive Services Task Force (USPSTF) pronouncement. While I can agree with much of what they are advocating, I am totally turned off when they label USPSTF as alphabet soup because the acronym is six letters long. To me this means that the ADA is belittling the USPSTF and does not show respect.

Then they use scare tactics by listing the serious complications that diabetes may cause supposedly to show how serious diabetes can be. If the ADA was actually calling for action and supporting the pronouncement of the USPSTF, you would think they could choose a more positive introduction. Diabetes receives enough bad publicity without the ADA adding to this.

Why they use the term Diabetes Advocates to apply to themselves is a puzzle. The email author then says, “This month our years of hard work paid off and the USPSTF recommended – for the first time – that Americans with key risk factors should be tested for diabetes. Studies show that currently more than half of people with undiagnosed diabetes are not tested because they do not meet the current diabetes screening guidelines. Now this will change!”

The author also says this matters because doctors around the country follow USPSTF recommendations. Then the email author says this is vital testing will be completely paid for by a patient's health insurance. Now this is where the two doctors I have been corresponding with have expressed caution. They both agreed that most private insurance companies may pay for the screenings, but will they pay for the follow-up appointments if the tests are positive. Medicare is the other concern as they have been in the habit of not paying.

The doctors do have a large concern about those that fall into the prediabetes range. Without the ADA making this an official classification, they feel this will still be an area that will not be covered, even with a prediabetes diagnosis.

The author of the ADA newsletter declared that the change is critical citing the estimated annual economic cost of undiagnosed diabetes is a staggering $18 billion. With this change, the 10 million Americans with undiagnosed diabetes and the 86 million with prediabetes will have a fighting chance to take action before the devastating complications of diabetes take hold, saving both lives and dollars.

The one thing that makes me hopeful – will the ADA do something about renaming prediabetes and make it an official diabetes designation? One can only hope.

Preparing to Present to An Outside Group

We are nearly finished for our November presentation to the group south of us. Their doctor has seen the outline and asked us to add the topic of prescription errors and maybe leave off the sleep apnea topic, as he would have a speaker for that. He was happy that Allen would be talking about the VA and those benefits, as several of his patients were veterans. He has asked us to arrive at 6:00 PM, as he wants to lengthen the meeting because of the topics we will be presenting.

A.J will be presenting about interventions, Allen will be presenting about the VA, Barry will be presenting about self-monitoring of blood glucose, Sue will be presenting about getting off medications, and I will cover the topic of prescription errors. My cousin will answer the questions she could not answer at the last meeting. Tim will operate the slide projector for all the presentations and Dr. Tom will answer a few questions that we may need help answering.

Dr. Tom has reviewed all of our topics and made a few suggestions to help us in our presentations. Dr. Tom asked Max to finish his topic on sleep apnea just in case and to come with the rest of us. Tim and Dr. Tom will be driving. My cousin will be driving alone. We will be attempting to keep our presentations under 15 minutes and allow 15 minutes for questions.

Today Tim received an email and forwarded it to the rest of us. The group will have about 35 members present and they are looking forward to our presentations. Dr. Tom has asked us to have some of the group we will be making a presentation to for our October meeting. We said no, because we wanted to welcome our new members and work with them during a meeting before exposing them to a meeting with other groups. We feel that it is important for them to get to know us and be able to ask questions in front of a smaller group.

Dr. Tom also informed us that Dr. Jay would not be discouraging our two groups, but he would not be promoting us. He said that he appreciated our honesty and that we did not dodge his questions. Dr. Tom did say that he was disappointed that we did say that we would not be favorable to doctors leading our groups. He continued that he told Dr. Jay that we encourage people to be testing their blood glucose levels more often than the ADA or the AACE. He told Dr. Jay that we encourage patients with diabetes to be tested for vitamin B12 and vitamin D, particularly those that had been on Metformin for several years.

He did ask if we had people with prediabetes in our groups. Dr. Tom said that each group only had at most one person with prediabetes. Dr. Tom did warn him that if he was not encouraging people to test or not giving out prescriptions for testing supplies, we would be opposing him and encouraging his patients to find another doctor. He said Dr. Jay was surprised by that, but said he was encouraging people to test and was requesting extra supplies for patients for at least six months even including the prediabetes patients who could not receive reimbursement. Dr. Tom did say that he was encouraging people to shop around for the testing supplies, but had found that the most reliable and least expensive was the Relion meter and test strips. He also suggests the Relion Prime and that people check Amazon for prices.

Join the Unprecedented Patient Dialogue with the FDA

I am quoting from the notice I received from diaTribe on 10-23-14 and remind everyone to participate, as I feel it is important.

We invite diaTribe readers to join an unprecedented patient dialogue with the FDA on November 3 from 1-4pm EST - you can register for the online webcast at www.cvent.com/d/z4qgt1/1Q. Even if you are only available for part of the conversation, we would strongly encourage you to sign up and join the virtual discussion based on our recent collective feedback.

As a community, it is essential that we show the FDA how committed we are to more open communication. Please register and join as a signal to the Agency that you are interested in dialogue, have valuable input to share, and want to advocate for better treatment options for diabetes.

Thanks so much from all of us at diaTribe!

Yes, this is one of the active groups promoting the survey and asking for your participation.  The last two days  have been very active.

I Can't Believe a Diabetes Forum Banned This

Some background on this first. In one of my newsletters from the ADA, I received information about a meeting of the Diabetes Organizations and some patient groups with the FDA. There was a survey link included to take a survey probably designed by the ADA or FDA, but there was at least one area for open comments which I made full use of in laying out many things we as diabetes patients need.

This blog references a great blog by Scott Strumello, which alone is worth the read, and then gives the link for the survey. This survey should be considered important and be completed.

I realize that diabetes forums need rules. I did post a thread about the information and encouraging people to take the survey. Here is what I was told - “We cannot permit surveys of any kind, in part (the part that most applies to this particular survey) because there is no way we can verify their authenticity. Surveys can be, and have been, used for marketing research, student homework, or phishing.”

Okay, the forum has a blanket rule forbidding any post about surveys even one this important. For forum members, this forbidding of this one does little to help the members learn about dealing with the FDA.

I hope many of my readers that are residents in the USA will complete the survey.

Another Questionable One-Size-Fits-All Pronouncement

Fortunately, there is still time to comment about this – until November 3, but this draft proposal is typical of their actions and they seldom back down or change little from the draft. Granted, they need to start someplace, but they need some flexibility in their pronouncements.

The draft statement by the US Preventive Services Task Force (USPSTF) says that the new focus is on identifying people with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). This is according to task force member Michael P. Pignone, MD, professor, department of medicine, and chief, division of general internal medicine, at the University of North Carolina, Chapel Hill, NC.

Since the USPSTF is a prevention and screening task force, I had to ask the doctors how they reacted to the Medscape article. They did agree that there needs to be some variables spelled out, but they could live with it.

The recommendation calls for screening everyone beginning at age 45 years, as well as younger adults with risk factors including overweight or obesity, a first-degree relative with diabetes, women with a history of gestational diabetes or polycystic ovarian syndrome, and certain racial/ethnic minority groups. This includes African Americans, American Indians/Alaskan Natives, Asian Americans, Hispanics/Latinos, and Native Hawaiians/Pacific Islanders.

The task force spokesman says that the proposed recommendations are generally in line with diabetes screening recommendations previously made by other groups, including the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists, the American Academy of Family Physicians, Diabetes Australia, Diabetes UK, and the Canadian Task Force on Preventive Health Care.

Both doctors felt good about some of it, but emphasized that they gave family history more importance than obesity, and felt that testing should be done earlier for women that had gestational diabetes. Both doctors agreed with this statement - Part of the task force's intent is to get physicians to think about lifestyle intervention more, and it's also a call to make effective lifestyle programs more available. They said this was important to make all doctors more aware and focus on this more.

I asked if they felt Medicare would allow this and reimburse doctors for the time. Both felt this would be the barrier and prevent this from becoming a reality. They also agreed that a major issue is how to follow up with those who screen positively. The felt that the cost of screening itself is quite inexpensive, but we have to think of the full spectrum of care that's required. Apart from cost, it's going to be hard to deliver good lifestyle-intervention programs to the large number of US adults who might benefit from them.

I appreciate my conversation via email about their perspectives and respect their putting me in a better mood

CMS Stranglehold on Medical Testing and Diagnostics

The Centers for Medicare and Medicaid Services (CMS) is up to its dirty tricks continually. CMS may become the laughing stock of the medical care world if they continue to restrict what health care providers can do. The rules are becoming so restrictive that even the CMS employees cannot keep up with the changes. With this, is it any surprise, that Medicare is projected to be insolvent by 2026, only twelve years from now?

More from the bad news side: Medicare will not pay for more than one test a year that is not directly related to the illness currently being treated by the doctor. In addition, Medicare rules forbid your doctor to treat (and therefore to test for) more than one ailment per office visit. What is the patient to do? Many people using Medicare have more that one medical problem and often three or more.

In theory, the patient could pay for the additional testing, but if those tests are deemed “medically unnecessary,” your doctor could go to jail for writing that prescription if he or she bills Medicare for the test. And if she or he wants to discuss the results of the test and prescribe a course of treatment, all discussion and treatment must be about that original ailment, even if you’re now sick with bronchitis instead. I am only guessing, but this sounds like if you have more than one illness, then you will need to see a different doctor for each disease or illness. How ridiculous CMS is becoming!

If a product or diagnostic test is new, getting Medicare to create a new billing code for it can take a long time and cost doctors a significant amount of money in lost reimbursements. And if a billing code exists, Medicare must agree to pay for the service. Medicare has not been willing to pay for genetic testing, except in screening for compatibility for kidney and bone marrow transplants. And with genetic testing to help individualize and personalized medicine, Medicare is unwilling to cover the level of genetic testing need for this to become a reality.

Medicare won't pay for physicians to consult with patients by email or over the phone, even if the patient is old, disabled, or too ill to come to the doctor's office. Medicare will not pay for doctors to teach diabetics how to monitor their glucose levels or manage their diabetes in other ways. The same goes for other chronic illnesses.

Read about Medicare and their restrictions and follow the many links in this article.