November 10th, 2005

Me dreamer

Three weeks for an antihistamine...

I have a patient. She is eleven, she is athletic, she has allergies and asthma and she needs an antihistamine. She has been on Allegra-D in the past; her symptoms resolved. Allegra has a generic. I prescribed Allegra. Medicaid informed me that I needed a prior authorization. I called them on a Saturday. "Oh," says the cheerful and friendly voice on the phone, "we covered her Allegra-D in the past, we should cover it again. I'll have the PA people look into it on Monday." Several days passed, and on Thursday I called again. They didn't know what I was talking about. I sent a PA form. They were very polite and refused. Medicaid informed me that she needed to be on Claritin, or that they needed documentation that she had tried over-the-counter medications in the past. I called her mother and verified that yea, indeed, Allegra was the end of a long chain of attempts. I sent that documentation - this had all been prior to my care. They waited a day before telling me that that was very nice, she needed to be on a formulary drug first, and would I please select from the following list of medications, including Zyrtec syrup, Atrovent nasal spray, Rhinocort Aqua, and several others. I wrote for Zyrtec chewables - after all she is eleven. I got a polite letter back saying that I must give her Zyrtec syrup instead.
What could I do? I wrote for the Zyrtec syrup and called her house and let her stepfather know that we were going to have to try Zyrtec. The poor man, he has no clue; his wife has been dealing with this with me.
What I don't understand, O Best Beloved, is why I can't prescribe the medication that's previously worked for this little girl's symptoms. I hate having to bow to the whim of people who think they know best. I am happy to change medications when my self-pay patient calls and tells me that she cannot afford her 1-gram prophylactic dose of Azithromycin ($30+); I will write her 7 days of doxycycline instead ($15) and not complain - I should have thought of that to begin with. I am not so happy to delay and delay as I am informed that no, I have to give oral Flagyl instead of vaginal gels (treat the infection where it bloody well is, is my thinking); I have to prescribe this antihistamine and not the other; I have to start at ground zero every time.
Now the converse: I am aware that formularies are the result of negotiations between drug companies and insurance companies; they allow cost savings to a degree not otherwise possible. I am not necessarily arguing against formularies - as long as they have a basis in evidence medicine (not all drugs in a class are always alike, after all) there is a place and a time for them. I am arguing that when I prescribe a medication and I want that specific medication for a specific reason, it is frustrating in the extreme to be told that my reason isn't good enough. It is even more frustrating to be arguing this with their specialists who know only what they are told.

It has been a bad day for prior authorizations.

It has been a good day for patients, if one does not mind doing vaginal exams all day. Six patients here of ten scheduled today : one pleasant gentleman who works for the food bank and tells me his blood sugars are out of whack thanks to eating fast food at the Hurricane Katrina relief site over the last few months, one woman with a painful right hand (no clue, folks, and a brand new mouthful of words to look up too - complex regional pain syndrome - which might be what she's got), my lady whose hair is falling out (still falling out, let's try Rogaine), and three pelvics - one follow up on chlamydia, one STD exposure (and boy, is she never going back to that boyfriend again), and one abdominal pain with pelvic tenderness. I spent half the morning looking in the microscope searching for bugs. I found a few.
I am still slow. I wish my six-year-old new patient had showed; she is cute and cuddly and I would like to see her again. But all of that is overshadowed by the fact that vacation begins now, and I am free of responsibilities until next Thursday morning.
That feels good.

Tomorrow, mom and Grandpa will be coming for dinner. Any suggestions? I have a meal planned; I'm looking for garnishes.
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