Richard M. Plotzker, MD


June 05, 2018

Medical errors have been part of therapeutic reality forever, and Murphy's law—whatever can go wrong, will go wrong—is engrained in students from the early days of medical school. Some misadventures are preventable, although they usually require a fail-safe system rather than 100% attentiveness on the part of worthy but fallible providers.

One relatively new challenge has been the emergence of formulary exclusivity for drugs that compete in the marketplace and are reasonably interchangeable, but have molecular differences that keep pharmacists from just making a therapeutic substitution as they would for a branded drug that has a generic available.

Diabetes, for Example

Management of diabetes has gotten more sophisticated, as basal insulins have expanded to five individual nonsubstitution prescription possibilities; prandial analog insulins are mired at three; and SGLT2 agents, DPP4 drugs, and GLP1-receptor agonists seem to expand their presence on pharmacy shelves every few months. Because all of them carry prices that far exceed the cash in my wallet even after making an ATM withdrawal, someone with pooled funds willing to pay those prices determines which brand will be covered. Usually that is a patient's insurance plan, but sometimes the decision rests with the hospital's Pharmacy and Therapeutics Committee, or sometimes the headquarters of a network that sits 2000 miles from the hospital pharmacy.

Every day, I get a message or two that a pharmacy needs preauthorization for a prescription I wrote. If the message is about insulin or test strips, I already know that a preauthorization effort will be futile. It's a brand problem, easily remedied with a phone call to the pharmacist who is usually happy to tell me which brand will make the order go through. Quick and easy, when you understand the problem and its solution. Unfortunately, some prescribers will take the preauthorization request seriously, fill out the form and get it rejected, since there usually is no contraindication to the formulary brand.

And Then Other Times...

This month I had to contend with two readmissions for severe hyperglycemia after I had just fine-tuned both patients' diabetes regimens. In both cases, the hospital's formulary insulin differed from the formulary insulin of the Medicaid plan.

The intern, who doesn't do enough office work to become proficient at this and was more involved in a hand-off than ongoing patient care, gets the directive from the hospitalist that the patient has reached his peak benefit of hospitalization, and therefore moves him along before the diagnosis-related group (DRG) worker gets mad.

Off to the current medicine list, copy and paste onto prescription forms, hand it to the patient who then goes to the pharmacy only to receive an ultimatum to yield his credit card or else. The dollar amount comes up on the screen, the patient freezes, hits cancel, and goes home without insulin, which the emergency department will be obligated to restore in a couple of days after another hyperglycemic episode.

So, to Murphy's corollary: You can make it fool-proof but you can't make it damn fool-proof.

So Who Is Responsible?

It may be tempting to find fault with the intern for this adverse, highly preventable outcome, but assigning blame to individual shortcomings rarely remedies a more fundamental challenge where repeat lapses occur in the absence of a more reliable process.

The reality is that insurers will not pay for expensive medicines unless there is a clear-cut need; those drugs are reserved for failure or intolerance to the more economical therapeutic options, and writing reasonable directives for step therapy to the more expensive drugs requires a certain amount of experience and perhaps a little savvy. This skill was never taught to me, because it was largely irrelevant in a day when prescription drug prices, while high, were not yet prohibitive. It is not taught to the house staff, either.

Who, then, is best suited for assuring that the adaptations to severe illness that typically occur in the hospital are sustained after the patient leaves the hospital? The intern has already been declared unprepared. The hospitalists? They probably are not familiar with equivalent alternatives to drugs in the hospital formulary.

Should it be the discharge planner assigned to each individual patient? That's where my vote would go, at least to match the medicines to the formulary, check off those that seem to be covered, and bring to the senior resident the identity of those medicines that are not, or that need a preauthorization with an appropriate medical reason for the request. Or perhaps it could be the senior resident who functions partly as provider, partly as mentor to the interns, and partly as the guy who has a "the buck stops here" patch on his white coat.

That responsibility may be of high educational value, teaching others that what we do in the hospital each day is not necessarily the only way to manage an illness. In the end, though, someone has to be responsible for patients obtaining their needed treatments without interruption, a glitch that can be truly memorable each time it occurs, and one that is at least theoretically preventable each time.


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