jmj11 Posted June 18, 2012 Author Share Posted June 18, 2012 This is a huge problem in my practice. I will put it in a scenario of Family Practice or IM (rather than headache treatment we will make it HTN). You see a new patient. They hare quite hypertensive. You prescribe appropriate anti-hypertensive medications. You give them a three month supply. You order labs. You schedule them back in two months. You get a call from the pharmacy in three months requesting a refill of their anti hypertensive medications. You look back and they had cancelled their follow up appointment just prior to it and never rescheduled nor did the labs. This happens to us about 5 times a day. I now have my office manager call them and reschedule in exchange for 1 month supply (these are not pain meds but migraine prevention meds). At the end of the next month, we play the game again. It is very time consuming for the practice. At what point do you simply deny refills? Do you send a certified letter? So, do you deny them their potentially life-saving meds? This cannot continue on forever. Link to comment Share on other sites More sharing options...
jmj11 Posted June 18, 2012 Share Posted June 18, 2012 This is a huge problem in my practice. I will put it in a scenario of Family Practice or IM (rather than headache treatment we will make it HTN). You see a new patient. They hare quite hypertensive. You prescribe appropriate anti-hypertensive medications. You give them a three month supply. You order labs. You schedule them back in two months. You get a call from the pharmacy in three months requesting a refill of their anti hypertensive medications. You look back and they had cancelled their follow up appointment just prior to it and never rescheduled nor did the labs. This happens to us about 5 times a day. I now have my office manager call them and reschedule in exchange for 1 month supply (these are not pain meds but migraine prevention meds). At the end of the next month, we play the game again. It is very time consuming for the practice. At what point do you simply deny refills? Do you send a certified letter? So, do you deny them their potentially life-saving meds? This cannot continue on forever. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 18, 2012 Moderator Share Posted June 18, 2012 devil's advocate: you call them back and they say "everything is wonderful. my "htn" is now well controlled to 120/80 on this rx that costs 4 dollars/mo. thank you so much. I really can't afford to see you in 2 months. because this is working so well can you refill my rx for a yr and I will see you next year? how do you deal with this scenario; the noncompliant happy patient? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 18, 2012 Moderator Share Posted June 18, 2012 devil's advocate: you call them back and they say "everything is wonderful. my "htn" is now well controlled to 120/80 on this rx that costs 4 dollars/mo. thank you so much. I really can't afford to see you in 2 months. because this is working so well can you refill my rx for a yr and I will see you next year? how do you deal with this scenario; the noncompliant happy patient? Link to comment Share on other sites More sharing options...
Contrarian Posted June 18, 2012 Share Posted June 18, 2012 I DO NOT write or refill prescriptions for patients that I can't do APPROPRIATE followup on. Regardless of why I can't do the followup. To do so is considered "bad-form" and "bad-medicine." No follow-up... NO refills. Another "devils advocate" scenario: So you refill the script for a few months due to consecutive excuses given as to why they can't get in. Patient is happy, all is good UNTIL... the patient has a poor/bad outcome. Do you NOT believe that the patient and their attorney will in$i$t to anyone who i$ li$tening that YOU had a DUTY to not $imply pre$cribe drug$ without appropriate follow up and therefire YOU $hould be held liable...?? :sweat: As I see it... If you can't spend 15 mins seeing me... then the pain coouldn't be that bad and you must be fine and don't need ANY of my services... to include the use of my DEA #. Because I have a DUTY to monitor you and your progress/decline. Especially if/when you are putting substances into your body that I ordered/approve/prescribed. But hey... that's just me... :wink: Contrarian Link to comment Share on other sites More sharing options...
Contrarian Posted June 18, 2012 Share Posted June 18, 2012 I DO NOT write or refill prescriptions for patients that I can't do APPROPRIATE followup on. Regardless of why I can't do the followup. To do so is considered "bad-form" and "bad-medicine." No follow-up... NO refills. Another "devils advocate" scenario: So you refill the script for a few months due to consecutive excuses given as to why they can't get in. Patient is happy, all is good UNTIL... the patient has a poor/bad outcome. Do you NOT believe that the patient and their attorney will in$i$t to anyone who i$ li$tening that YOU had a DUTY to not $imply pre$cribe drug$ without appropriate follow up and therefire YOU $hould be held liable...?? :sweat: As I see it... If you can't spend 15 mins seeing me... then the pain coouldn't be that bad and you must be fine and don't need ANY of my services... to include the use of my DEA #. Because I have a DUTY to monitor you and your progress/decline. Especially if/when you are putting substances into your body that I ordered/approve/prescribed. But hey... that's just me... :wink: Contrarian Link to comment Share on other sites More sharing options...
OrthoSurgeryPA Posted June 18, 2012 Share Posted June 18, 2012 This is all too common in my current practice. The pharmacy will issue the pt quantity sufficient until seen by their primary care manager (MD/DO, PA, NP). This is usually no greater than 1 week. If the pt does not f/u in a timely manner then they do without. No "blind" refills anymore unless they have a converstion with one of us by telephone and we authorize a refill. This is why all my initial encounters wth pts have verbage stating what goals are for tx and specific f/u instructions. This also helpful because with the current med homeport model the military has gone to I commonly see other provider's pts and they see mine. It's all spelled out (hopefully). Then I feel no reservation about attaching the "noncompliance with therapy" V15.81 code to a pt's record. I think some are less apt to do so this but it certainly warranted once a pt shows that they intend to continue being noncompliant with tx goals. Link to comment Share on other sites More sharing options...
OrthoSurgeryPA Posted June 18, 2012 Share Posted June 18, 2012 This is all too common in my current practice. The pharmacy will issue the pt quantity sufficient until seen by their primary care manager (MD/DO, PA, NP). This is usually no greater than 1 week. If the pt does not f/u in a timely manner then they do without. No "blind" refills anymore unless they have a converstion with one of us by telephone and we authorize a refill. This is why all my initial encounters wth pts have verbage stating what goals are for tx and specific f/u instructions. This also helpful because with the current med homeport model the military has gone to I commonly see other provider's pts and they see mine. It's all spelled out (hopefully). Then I feel no reservation about attaching the "noncompliance with therapy" V15.81 code to a pt's record. I think some are less apt to do so this but it certainly warranted once a pt shows that they intend to continue being noncompliant with tx goals. Link to comment Share on other sites More sharing options...
CDHart Posted June 19, 2012 Share Posted June 19, 2012 The clinic I was at as a student had a no phone/fax refill policy. It simply stated "we prescribe you enough medication to get to the next time you need to be re-evaluated. If you are out of medication, you need to come in and be seen." At most a person who had been stable on HTN meds for years would get 6 months, most newer patients would be seen every 3 months till "stable" on their regimen. By stating it up front, with no exceptions, it flew with the patients. Link to comment Share on other sites More sharing options...
CDHart Posted June 19, 2012 Share Posted June 19, 2012 The clinic I was at as a student had a no phone/fax refill policy. It simply stated "we prescribe you enough medication to get to the next time you need to be re-evaluated. If you are out of medication, you need to come in and be seen." At most a person who had been stable on HTN meds for years would get 6 months, most newer patients would be seen every 3 months till "stable" on their regimen. By stating it up front, with no exceptions, it flew with the patients. Link to comment Share on other sites More sharing options...
Joelseff Posted June 19, 2012 Share Posted June 19, 2012 I like the QS rx until their next visit but ill admit, I am more lax on htn meds but like a good rate of followup esp for my elderly pts who go one way or the other on what seems to be a flip of the coin. I would call the pt to schedule. Once appt is scheduled, write for QS to the date of appt. If habitually evasive, no more fills until they cone in, charge them cx/ns fee, then if still evasive they are put on our walk in only list. "no appointments for you!" (soup Nazi voice) If still evasive.... "bye, bye, byeeee" Sent from my myTouch_4G_Slide using Tapatalk Link to comment Share on other sites More sharing options...
Joelseff Posted June 19, 2012 Share Posted June 19, 2012 I like the QS rx until their next visit but ill admit, I am more lax on htn meds but like a good rate of followup esp for my elderly pts who go one way or the other on what seems to be a flip of the coin. I would call the pt to schedule. Once appt is scheduled, write for QS to the date of appt. If habitually evasive, no more fills until they cone in, charge them cx/ns fee, then if still evasive they are put on our walk in only list. "no appointments for you!" (soup Nazi voice) If still evasive.... "bye, bye, byeeee" Sent from my myTouch_4G_Slide using Tapatalk Link to comment Share on other sites More sharing options...
ToppDog Posted June 19, 2012 Share Posted June 19, 2012 I've seen pt's discharged from care over it many times. My all time fave was one doc that went so far as to call in one days worth with zero refills every day until the patient got tired of going to the pharmacy every day for his meds & finally came in for an appointment. He was compliant from then on :) Link to comment Share on other sites More sharing options...
ToppDog Posted June 19, 2012 Share Posted June 19, 2012 I've seen pt's discharged from care over it many times. My all time fave was one doc that went so far as to call in one days worth with zero refills every day until the patient got tired of going to the pharmacy every day for his meds & finally came in for an appointment. He was compliant from then on :) Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 19, 2012 Moderator Share Posted June 19, 2012 Two seperate issues 1 - on ANY controlled substance - opiates, narcs, benzos', stimulants, sleeping pills - sorry no follow up no refills - and I do 3 month follow ups and random Utox as well - yes strick on evil drugs 2 - on HTN or other "medicine drugs" I am much more flexible. If the value I am trying to control was WAY bad - ie 200/120 or A1C of 12 I pretty much insist that they come in for follow up - but likely only one month F/U at starting. If they are stable and I have documented that they have good control of what ever we are managing I tend to stretch it out a little bit - ie 6 months and then if they are not able to f/u I might just order any required labs and only give them a refill to cover getting labs. If the med does not require labs (ie ccb or alpha blocker) then I just doocument I spoke with them. However I NEVER go beyond a year with out a follow up - no appointment - no meds.... chronically ill patients (those taking a script medicine) deserve to be seen at least yearly as a check in, physical. So in the situation where the drug it working well (and I have documentation to this effect) I might go out to a Max (andd only with my arm tiwsted) of 13 months - 6m cancel, then they cancel 12m and I only give them one month to get in. After that - sorry out of luck...... Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 19, 2012 Moderator Share Posted June 19, 2012 Two seperate issues 1 - on ANY controlled substance - opiates, narcs, benzos', stimulants, sleeping pills - sorry no follow up no refills - and I do 3 month follow ups and random Utox as well - yes strick on evil drugs 2 - on HTN or other "medicine drugs" I am much more flexible. If the value I am trying to control was WAY bad - ie 200/120 or A1C of 12 I pretty much insist that they come in for follow up - but likely only one month F/U at starting. If they are stable and I have documented that they have good control of what ever we are managing I tend to stretch it out a little bit - ie 6 months and then if they are not able to f/u I might just order any required labs and only give them a refill to cover getting labs. If the med does not require labs (ie ccb or alpha blocker) then I just doocument I spoke with them. However I NEVER go beyond a year with out a follow up - no appointment - no meds.... chronically ill patients (those taking a script medicine) deserve to be seen at least yearly as a check in, physical. So in the situation where the drug it working well (and I have documentation to this effect) I might go out to a Max (andd only with my arm tiwsted) of 13 months - 6m cancel, then they cancel 12m and I only give them one month to get in. After that - sorry out of luck...... Link to comment Share on other sites More sharing options...
jmj11 Posted June 19, 2012 Author Share Posted June 19, 2012 To carry this further . . . at what point would you do a legal dismissal? What if Mr. Smith didn't keep his appointment, you didn't refill his anti-htn meds and a month later he has a stroke . . . would you be libel without a formal, legal dismissal or . . . even with one. This created a real problem when I followed a lot of seizure patients (who are notorious for noncompliance). I bent the rules over and over because I knew the week they came off their drugs they could have a seizure, probably behind the wheel and kill someone (most likely an innocent family). I only stopped refilling them, month to month, after I had a certified letter signed by them indicating they had received my dismissal letter. Now, as a business owner, who is trying hard to keep a good PR, it is a constant balancing act. I refill until their next appointment. They call a few days early . . . "mom passed away in Kansas, can you give me another refill." Then you refill for a month. They cancel the next appointment, "I can't miss work right now because it is too busy." Do you then give them another grace period for a few weeks? I usually don't but it is a gray line at what point you pull the plug. Of course I never refill controlled substances if they miss an appointment. Link to comment Share on other sites More sharing options...
jmj11 Posted June 19, 2012 Author Share Posted June 19, 2012 To carry this further . . . at what point would you do a legal dismissal? What if Mr. Smith didn't keep his appointment, you didn't refill his anti-htn meds and a month later he has a stroke . . . would you be libel without a formal, legal dismissal or . . . even with one. This created a real problem when I followed a lot of seizure patients (who are notorious for noncompliance). I bent the rules over and over because I knew the week they came off their drugs they could have a seizure, probably behind the wheel and kill someone (most likely an innocent family). I only stopped refilling them, month to month, after I had a certified letter signed by them indicating they had received my dismissal letter. Now, as a business owner, who is trying hard to keep a good PR, it is a constant balancing act. I refill until their next appointment. They call a few days early . . . "mom passed away in Kansas, can you give me another refill." Then you refill for a month. They cancel the next appointment, "I can't miss work right now because it is too busy." Do you then give them another grace period for a few weeks? I usually don't but it is a gray line at what point you pull the plug. Of course I never refill controlled substances if they miss an appointment. Link to comment Share on other sites More sharing options...
burnpac Posted June 19, 2012 Share Posted June 19, 2012 Agree with Contrarian on this one. Safe prescribing mandates an ongoing and documented relationship with the patient. If they don't want to play by established rules and the standards of care, then they can find another provider. Link to comment Share on other sites More sharing options...
burnpac Posted June 19, 2012 Share Posted June 19, 2012 Agree with Contrarian on this one. Safe prescribing mandates an ongoing and documented relationship with the patient. If they don't want to play by established rules and the standards of care, then they can find another provider. Link to comment Share on other sites More sharing options...
mackjacks Posted June 20, 2012 Share Posted June 20, 2012 Related question: Say a young pt is away at college; their only script is Retin-A Micro. Pt says it's working great on their skin and wants a refill, is that annoying? ...full disclosure, I did this in undergrad. I figured their practice is really busy and they'd rather be billing on in-office procedures and the like vs seeing me? Link to comment Share on other sites More sharing options...
mackjacks Posted June 20, 2012 Share Posted June 20, 2012 Related question: Say a young pt is away at college; their only script is Retin-A Micro. Pt says it's working great on their skin and wants a refill, is that annoying? ...full disclosure, I did this in undergrad. I figured their practice is really busy and they'd rather be billing on in-office procedures and the like vs seeing me? Link to comment Share on other sites More sharing options...
OrthoSurgeryPA Posted June 20, 2012 Share Posted June 20, 2012 Related question: Say a young pt is away at college; their only script is Retin-A Micro. Pt says it's working great on their skin and wants a refill, is that annoying? ...full disclosure, I did this in undergrad. I figured their practice is really busy and they'd rather be billing on in-office procedures and the like vs seeing me? Male or female pt? I always make sure to have that statement that "have advised pt of Cat C warning..." Our derm guys have a dedicated form for it for CYA purposes, that is how serious they are about it...even for topical. Link to comment Share on other sites More sharing options...
OrthoSurgeryPA Posted June 20, 2012 Share Posted June 20, 2012 Related question: Say a young pt is away at college; their only script is Retin-A Micro. Pt says it's working great on their skin and wants a refill, is that annoying? ...full disclosure, I did this in undergrad. I figured their practice is really busy and they'd rather be billing on in-office procedures and the like vs seeing me? Male or female pt? I always make sure to have that statement that "have advised pt of Cat C warning..." Our derm guys have a dedicated form for it for CYA purposes, that is how serious they are about it...even for topical. Link to comment Share on other sites More sharing options...
Contrarian Posted June 20, 2012 Share Posted June 20, 2012 Related question: Say a young pt is away at college; their only script is Retin-A Micro. Pt says it's working great on their skin and wants a refill, is that annoying? Yeah... ok. Then you get the letter from her OB stating that her amniocentesis in abnormal and asking you to send the copy of the last pregnancy test you ordered... since they already have copies of all 6 refills you authorized. Fun times ahead...:sadface: Link to comment Share on other sites More sharing options...
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