Help!? Career forcing me to push statins

#1

I am a pharmacist who has completely embraced the lchf and IF way of life. What seemed at first to be the greatest help i could actually provide to my patients is proving to be impossible - improving health through diet.

Here’s the story.

I work at a big retail chain and I have to make phone calls to diabetic, hypertension and statin patients about their medications. The whole purpose of this is to get people to take them exactly as prescribed and never miss a dose. (The real reason for the push is insurance companies reimbursements decrease if patients don’t take their medications on schedule). Calling them about hypertensive and diabetic meds, although an awkward conversation, is no problem because sometimes I can talk to them about changing the sugar flow into their body. The part I struggle with is advising ALL diabetics to be on a statin. This is a metric that the insurance companies use to decrease our reimbursement and ultimately pay us less for every prescription. I don’t know how I can recommend to patients and prescribers that a statin needs to be added in every diabetic when I question the validity of this guideline.

My job is literally starting to depend on this. If we can’t improve the patient’s adherence and start statins, we will lose contracts with insurance companies. Our hours have already been decreasing and I have been told that if we don’t fix this we will lose more. Morally I don’t think I can promote a therapy that I find questionable at best.

Any other health care providers have any ideas?

(Omar) #2

See if there are other drugs that can be added to the bundle and can be genuinely beneficial to the patients.

#3

This measure is statin specific. Even if the patient is allergic, it counts against the pharmacy

(Brian) #4

Maybe a change of jobs (or careers) is in your forecast. (?)

(You've tried everything else; why not try bacon?) #5

What I’m not grasping is the benefit to the insurance company of pushing statins. Surely the fewer prescriptions they have to pay out for, the more money they get to keep? I’d also be curious to know how they justify forcing a statin on patients who are allergic to it. That seems not just peculiar, but illegal.

(You've tried everything else; why not try bacon?) #6

I just want to throw into the discussion that while it is clear that statins do lower LDL, there is no evidence to support the theory that lowering LDL lowers the risk of cardiovascular disease. In fact there is mounting evidence to show that lower LDL means a greater risk.

Also, a case could be made that the statin manufacturers have fraudulently minizmized the risk of side effects in their published studies, which one would think would lead them open to a massize lawsuit. Objective studies show a much higher risk of serious side effects.

I have posted links to a number of lectures by David Diamond, in which he discusses these very points.

#7

Wait. Am I misreading this? A pharmacist (not a doctor) makes phone calls to advise diabetic customers to take a statin? (Or is the phone call just to confirm that the prescribed statin is being taken properly?)

(Todd Allen) #8

In light of many studies indicating statins are a significant risk factor for developing diabetes, muscle wasting, liver and kidney problems and studies indicating they don’t improve life expectancy but rather shift causes of death I’d hate to be in a job where I had to promote their use to people based on a doctor’s prescription without being able to investigate each case to be sure that prescription was made on the basis of a thorough process to insure it really is in the patient’s best interest.

(Ken) #9

Tough subject. I can imagine the conflict that would arise if doctors or pharma companies found out you were recommending people to not follow their treatment instructions.

About all you can do is recommend something like The Magic Pill and hope people will figure it out themselves.

#10

MTM.

Guidelines are a double edged sword. They force health professionals to push treatments because to not do so would be against the grain and in the event of any complications open one to a lawsuit.
My labs are fine, but my MD still wanted to start statin therapy because of my total risk factors including age, weight, smoking history. He knew from the get go I wasn’t going to do that, but he had to bring it up and document me declining it. That way if I keel over in the near future there will be plenty of CYA docs stating he did advise me concerning statin therapy and I declined it.
Our system is far more messed up than most people realize.

And as far as Pharms advising on meds vs MDs…I hate to break it to anyone but chances are your PCP of any flavor (MD, DO, FNP, PA) doesn’t know enough about medications to fill out a first year college essay, let alone the encyclopedic knowledge required to really manage pharmaceutical therapies. There are always exceptions, but by and large medication ignorance is the rule.

As for changing jobs, good luck. All the corporate places are largely the same.
All the independents are largely gone.
All the new PharmDs are largely in debt to the tune of 100k+

You can always take the big pay hit and go to Clinical…if you have the resume for it and the willingness to argue with providers and nurses day in and day out.

#11

Learn something new every day! Just googled it. Fascinating.

(Todd Allen) #12

Me too. And from the wikipedia page:
https://en.wikipedia.org/wiki/Medication_therapy_management
“As of 2015 there was no good evidence that MTM created better outcomes for people or that it saved money.”

#13

There’s still something odd in my mind of a pharmacist (with no knowledge of patient’s family history or other health issues, etc.) pushing or suggesting a medication on a patient directly. (Unless the dialogue is “you should ask your doctor if drug X is right for you,” which is basically what every drug advertisement says anyway. If it’s more pushy than that, it’s somewhat unseemly, in my view.)

I have less of a problem with the pharmacist urging prescribers to do so. That’s professional-on-professional dialogue. I’m fine with that, and it’s apparently a big thing: https://www.japha.org/article/S1544-3191(17)30155-3/fulltext

(Todd Allen) #14

It looks to me like the study showed pharmacists could prompt doctors to get more of their patients on statins but no attempt was made to evaluate whether that resulted in a benefit to the patients.

#15

Agreed. Yep. Two entirely separate issues (the latter being the more important).

#16

Yep. Keep in mind most pharmacists have a doctorate and know more about the treatmeant guidelines and goals than prescribers. I call the patients, discuss their disease state and cite the recommendations that all diabetics also need a statin for cv prevention. If they agree I call the prescriber I get the order for the medication.

I just happen to disagree with the guidelines

#17

This makes sense to me. And I definitely agree you know more than most primary care docs. The hiccup in my mind though was your lack of access to the broader medical picture in the EMR. But, alas, if under MTM you leave the final prescribing decision to the prescriber, then that makes complete sense. (Except for the guidelines part, of course.)

#18

Changing jobs or practice sites is not an option given my location (population of less than 50,000 in a 100 mile radius). Honestly don’t get me started on the broken system of pharmacy and debt . At this point I’m lucky to have a job

#19

As a rule the Pharm does have more detailed records for the purpose of MTM. (ETA: Or we are supposed to. One reason my system took this on at the clinical level…though it is still nigh onto impossible to get paid for it.)
In terms of guidance, it is more something like this: Patients being treated for X should also be taking Y. Or, patients being prescribed Y should also be taking Z. Based of supposed long term outcome studies.
At the retail level there is very little dialogue with actual prescribers, the best one can hope for is getting that providers nurse. You might be stuck with office staff. You are definitely going to be leaving a message for someone.
Providers do not want a dialogue with Pharms for a few primary reasons:

  1. It questions their authority. Many providers have issues with that, despite all of the “healthcare team” BS of the last decade or so.
  2. It exposes their ignorance. They really don’t like that.
  3. They don’t have the time. Cramming in 5-8 patients an hour is a bad way to have effective healthcare. And the typically have no choice in the matter.

Previously Pharmacists had little to no motivations to push particular drugs because they did not receive any sort of compensation for doing do.
These new guidelines are from insurance companies, not Big Pharma. You will do what they want or suffer consequences to you reimbursements. Think of it as the opposite side of the kick-back coin. The pressure comes from the employer themselves. You will fall inline with the guidance provided, assumed to come from long term studies or meta analysis that suggests these forms of treatments result in better outcomes that ultimately cost insurance companies less money.
Or you will be fired.
Look up the issue with filling metrics being used at retail Pharmacies if you really want to be terrified.

(karen) #21

I don’t think there is any way you can fight this up front. Which gives you two choices: find another job, or go commando. - No, you can keep your underwear on, that’s ok. :grin: What I mean is, you are in a unique position to collect a private email database of people who you know are being personally pushed to take statins, and then contact them under a pseudonym on your own time (for privacy reasons, you could skip their names and just keep a list of email addresses, this isn’t about invasion, just information). For example, to send them personal email from 'The Alternative Pharmacist," urging them off statins with as much clean and easy data as you can find.

This isn’t going to help your job situation. But it might ease your conscience or save a life. Sorry to offer such depressing alternatives, but Big is going to kill us, maybe it’s time to take a stand.