Tuesday, July 31, 2012

The Government Stole My Patients' Medicines

     The daughter of an elderly patient called me at home over the weekend.
     "Can you help my mother?  She's running a fever--and she's not eating."
     "I haven't seen Mrs. M.  for a year," I answered.
     It's unfortunate, but we stopped taking Medicare patients at my clinic when the government (we presume) instructed Medicare to stop paying us for our work.  It took six months of zero payments for us to realize the Medicare--the insurance carrier for people over sixty-five-- had no problem letting us see patients for free, forever.  (Is that legal?)
     "How has she been doing, otherwise?" I asked.
     "It's bad," the daughter said.  "She broke three bones in her arm last week.  They couldn't do surgery, and sent her home.  Now she has a fever."
     We had been treating Mrs. M.'s osteoporosis with yearly Reclast--administered in our office through an IV.  The treatment is quick and easy--and an exceptional way to reduce fractures in older patients.
     In fact, data on bisphosphonates like Reclast shows a thirty to fifty percent reduction in fractures in people treated the first year.  The trouble is, patients won't take oral bisphosphonates:  the pill causes reflux, it's hard to remember the dosing schedule, and the restrictions about not eating or lying down afterward are annoying--especially for older people, easily confused.  But patients will come to the office once a year for Reclast.  It's a fantastic product, except for the cost.
     Medicare pays doctors to administer Reclast, as it should--but its reimbursement for the medication is $200 less than the cost to buy the medication.  (IV Boniva is similarly under-reimbursed.)  I told my nursing supervisor--who maintains inventory--that if we couldn't find Reclast at a break-even price we wouldn't be able to administer it to patients.
     She did her research and found a reasonable price for the product at Northwest Pharmacy.  We were able to buy two other important injectable medications from Northwest at prices that allowed us to use them in the office:  Synvisc, and Boniva.  For the first year at Colasante Clinic we gave Reclast (and the other two medications) to patients whose medical problems justified its use.  I believe these medicines prevented fractures--and saved lives.
     I have been using Reclast for six years.  The fracture rates for patients in my practice plummeted after we started administering it.  Patients would take calcium and Vitamin D, have their kidney function checked with a lab test, get Reclast in our office--and get on with their lives.
     It's a fact that in Family Practice we don't get credit for most of the good things we do.  Patients love us, but they don't come back and say, "Hey Doc, Thanks--I haven't had a fracture!"  They don't appreciate that they didn't get pneumonia or the flu after we vaccinated them, or that they didn't have an unplanned pregnancy after we inserted an IUD.  It's hard to register the absence of a problem.  But we know we're doing the right thing for people, and that's what matters.  I knew that giving IV Reclast was saving my patients from having fractures, just as I had observed that putting them through vestibular training would correct the balance-related falls so common in older folks.  Patients don't write me notes saying thank-you, they haven't fallen.
     Today a patient came to see me, and started crying as soon a I sat down and looked at her.
     "You know my husband died six weeks ago?" she told me.
     No, I hadn't known.  I hadn't seen Mr. B. for more than a year--another Medicare patient.  He, too, had been getting Reclast--until we stopped giving it.
     "What happened to him?" I asked, feeling downhearted.  I was remembering how Mr. B.  had always stood up when I entered the room, and given me a little bow.  I remembered that he was freshly shaven for his appointments, his shirt was tucked in, and his hair neatly combed.
     "He fell and broke his hip," she answered.  "He died seven days later."
     One-third of the patients who sustain hip fractures die within six months--of something.
     Why did we stop giving Reclast?
     Because the FBI took our entire stock, during its raid of my clinic on June 16, 2011.  The agents took all the Boniva, too, and ninety IUD's, aas well as the Synvisc we were using for patients with disabling knee arthritis--people who were grateful for the treatment because they could not undergo surgery.
     The medications taken by the FBI in their rampage on my clinic totaled $100,000.
     As it turns out, the distributor for these medications, Northwest Pharmacy, is located in Canada.  The products were brand-name, made by the original manufactures (e.g., Merck), sealed in their original packaging, checked and approved by U.S. Customs officials at the border (the boxes officially stamped, according to nursing staff)--then shipped to our office.
     Providers don't order medications, nor do they open boxes of supplies.  I signed off on the orders, which were handwritten by my nursing staff on our purchase order forms.  The nursing staff has always been excellent in my office--high caliber individuals with great integrity.  They want to do a good job.  I was glad they had found the products my patients needed at a price we could justify.  My practice management magazines caution doctors against "doing everything yourself because you don't trust anyone in your office." They say it's bad not to delegate.  I trusted my nursing staff--and why not?
     Is there something wrong with products shipped from Canada?
     Or is there something wrong with a government that has made it acceptable for the pharmaceutical industry to price products out of reach for the people who need them in this country, and illegal to purchase them at a lower price from another country?  If it's illegal, why doesn't the American government tell the Canadian government to stop selling American products to Americans through Canada?
     Do the products come from Canada?  Or do they come from the United States, where they are manufactured?  In truth, most pharmaceuticals are manufactured abroad, but they're still "from America" unless they've been sold to another country.  At a meeting with my lawyers one of them looked at his bottle of Prilosec--purchased at CVS.  "Hey!" he interrupted us. "It says, 'Made in India'--right here on the label."  Is that legal?
     Isn't half of everything we buy in this country made in another country, or shipped from another country?  Isn't Reclast--"American-made"--made by non-Americans. in another country?
     Are you confused?  I am.  And I don't know how many more booby-trap rules for doctors I can stomach.  American physicians must be the most regulated human beings in the world.
     I never saw the website for Northwest Pharmacy, but I saw some of the faxes they sent us every day, advertising their competitive prices--and they didn't say, "Canadian products."  In fact, their flyers said these were American products, and they had more than 50,000 American doctors as customers, as well as hundreds of  thousands of satisfied clients.  I thought they were trying to reassure doctors that they weren't some hole-in-the-wall place in, say, Timbuktu.      
     My lawyers are confused, too.  They investigated the situation surrounding "Canadian medicines." Everyone knows that for twenty years Americans have been buying the American medicines they need from Canada at 30% less than in the United States.  It's a crime to do this.  But my lawyers tell me that the government has decided not to intercede when individuals buy Canadian medicines.  They'll "decide" whether and when to arrest doctors, however, on a case-by-case basis.
     It's against the law to buy Reclast from a Canadian pharmacy, I'm told.  It doesn't matter if it comes in its original, sealed packaging from American pharmaceutical companies (which it does), or that the chain of custody can be traced with exactness.  We physicians are required by law, if we wish to treat our patients appropriately, to purchase what they need at $200 more--in the case of Reclast--than we will be reimbursed by Medicare.  And it's illegal for patients to pay the difference (as many have offered to do)--Medicare "sets" the prices we're allowed to charge, Medicare pays whatever it likes, and the government makes it a crime for doctors to do anything except take a loss.
     Oh...we can also withhold treatment from the patient.
     I know the government doesn't care about my patients, the ones who are now suffering fractures and accepting this as part of old age.  If it did its FBI agents would give back my patients' medicines, which were ordered for individual patients, and let me make the decisions about medical care. Osteoporotic fractures are not a fact of aging, not if patients have access to the medication they need--and I want to help them. 
     But since the raid on my clinic and attack on my character by the FBI, I'm beginning to wonder if I can help anyone at all, any more.

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