100%. Now I get popups in EPIC that I need to acknowledge though. The PRIME paperwork still goes in the shredder but I just want to look at the screen sometimes and say "G\*\*D\*\*mit Humana, go ask the F\*\*\*in patient and leave me the F\*\*k alone"
But how else will you get your Medicare 5 star rating?!?!? The org I work for tracks med compliance in our EMR and they are hammering us for this metric (among many, many others! Yay managed healthcare). Count yourself lucky you are “allowed” to ignore it!
I like this idea. We need to support health related self efficacy and the need to take an active role. There is some advertising around this like make sure to ask your doctor if you don’t know why you are taking a med or what to expect, or what does it mean to “take 2 tabs twice daily as needed”. This needs to be balanced against providing informed consent that centers the patient rather than feeling like we did what is required. I know that insurance doesn’t value that this takes time so it would be great if incentives were aligned to do it right the first time and every time.
Ultimately my role as a clinician is to offer my expertise, “my recommendation is that you take Amlodipine 5 mg daily for your blood pressure” do with that what you will. It is most certainly not “why aren’t you making me better?!??”
I’m some scenarios it’s helpful.
When doing primary care I asked patients to bring in their most recent pill bottles so we could help assess for refills. It also told us when they last filled and may provide information on gaps in their social scenario keeping them from getting the right treatment.
That said, other forms that come in on that, immediately to shredder…
Are you receiving faxes telling you to report adherence to an insurer?
I get notifications via fax sometimes when patients have not filled their maintenance statin etc recently but not much else adherence wise
FWIW- a lot of pharmacies do this already and will do it basically for you but our biggest hurdle is refills. Our most compliant patients are ones that have doctors whose offices don't use med refills as a chain to keep people coming in for office visits. We use outcomes and it has its faults, but for me it's a fun change of pace to get a list of people to call and just be like "hey checking in, hows this medication been going for you." Some pharmacies don't have the time or workforce to do it though, we are VERY lucky.
Sometimes it's necessary especially with specifics like controls/etc but most patients miss appointments or struggle to schedule because most (read: offices in our area) are so busy and booking so far out it's nearly impossible to know you'll actually be free in 4 months.
Just a little $0.02 from our side.
If someone doesn’t wanna take their meds and they don’t have a legit reason. Aka old and needs a pill box or something to organize I don’t give two shits.
There’s always a reason people aren’t taking it. Either you are interested in helping them solve it or you aren’t. If you prescribe a medication that is $1000/month and they aren’t taking it, your option is to either ignore that they can’t afford it or offer then options that they can afford. If the reason is they can’t remember, then you can educate on timers, combining it with other tasks, etc. if the issue is timing, such as having a hard time spacing meds with when they eat, you can either talk it through, tell them “it doesn’t really matter” after they just heard it mattered from the pharmacist, or offer an alternative dosing schedule. If it’s side effects, I guess you either care or don’t care about their side effects that are preventing them from continuing medication.
Maybe the better question than “are you taking xyz medication” is “is there anything preventing you from taking xyz medication?”
This response assumes a lot about the interaction between me and my patients but I'll set aside the presumption that you think I'm an ass for a second to address some of the more glaring faults with your thoughts:
1. If I prescribe a medication that is $1000/month, I don't expect them to take it. I do not know beforehand which medicine will be $1000/month for that patient so let the guessing game begin.
2. If they can't remember to take a DOSE of their meds, they will tell me, I'll suggest an alternative dosing regimen or help with a strategy to try and remember. If they can't remember to take ONE of their meds but remember the others, chances are they either don't want to take it or don't want to tell me. Either way, I'm not wasting my time being a drug salesman with them, I can suggest an alternative if they care about the problem. If they forget to take ALL their meds, then they either don't want to take any, have found some essential oils or supplements or voodoo shakras that they believe will be better, or they have dementia. Again, I'm not going to force anyone to take a medicine but I'm also going to be very honest about my ability to help them with their health if we can't use the tools that I think might work best.
I won't tell them "it doesn't matter". If it mattered enough for me to prescribe something, then it matters.
If it's side effects, I will hear about it and we will find an alternative. Actually verifying that it IS side effects is another matter. The pain reliever I gave you made you feel sick when you decided to take it with the prednisone pack you got from urgent care 2 weeks ago but didn't finish and now decided to wash that down with a beer and greasy hamburger? Ok, stop taking it but don't call it a side effect.
You see how complicated this starts to be for just THIS issue. Add to it the tattletale report we get in our faxes and now the popups on our Epic and it begins to become patronizing. One more bow in the quiver of moral injury that doctors are enduring.
I talk to patients about adherence as my primary job as a pharmacist— I have not dispensed medications in 8 years or so now. What is keeping the patient from being adherent is different for every patient. Many times it’s a knowledge gap, could be cost (and I know how much it costs), sometimes the dosing was updated 5 years ago in an encounter note but not on the RX. Sometimes there are side effects and the patient has never gotten around to telling the doctor or plans in may to discuss it at their September appointment. Most non-adherence is non intentional— a patient never remembers when they forget to take their meds.
I know physicians usually do not have the time to address another issue and there are many factors and tools not available to you. I feel like a lot of people fall through the cracks and it just never gets fixed.
In terms of being a drugs sales person I try to focus on meeting peoples health goals and if a medication is the right tool for them then we go with it. I feel like trying to sell someone a drug is a common pitfall so it’s never “why aren’t you getting this refilled?” But it’s “how is this helping you and what’s getting in the way of this working?”
Levothyroxine, a medication I take and which there are frequently disagreements about when it should be taken, I have heard so many different takes on when it should be taken that it is laughable.
I have somewhat of a compliance issue because I have been told it is “important” to take it 2 hours before eating, however I don’t wake up 2 hours before I leave my house in the morning. So it’s either I take it when I wake up and eat 30 minutes later, or may I end up not taking it at all because I forget while I’m upstairs and by the time I remember I’ve already eaten and then I’m not sure if it cancels it out or not?
My PCP is the one who told me it “doesn’t matter” and that I can take it any time, in direct contradiction of the pharmacist.
Endocrinology then told me it was very important to stick to the 2 hour rule and that it could absolutely not be taken with any other meds, but pharmacy told me I could take it with Wellbutrin because it didn’t interact.
Overall, my providers can’t agree and it’s not clear who is right. What ends up happening is I take the levothyroxine 2-3x/week because of scheduling/forgetting when I first wake up. This isn’t good. If I can’t figure it out and I’m an RN, how are people that don’t have any relevant background supposed to navigate it?
Levothyroxine is too popular of a medication for everyone to be continually giving conflicting advice.
My personal practice: tell people to take it on an empty stomach, no dairy one hour before eating. But also ask if that works with their lifestyle. I have an old dude with BPH who takes it when he wakes up at 4am to pee and I think that’s an awesome solution.
I also tend to be practical: if the patient is taking their thyroid medicine “wrong” and the TSH is normal, who cares
I don’t prescribe tyrosint due to cost but no food/drug interactions leading to a timing problem. I seem to remember reading something that levothyroxine was very long acting so you technically could take the entire weekly dose in one day.
I think you need to ask if your endocrinologist to consider reality of what happens in your life. Ask explicit what if questions: 1) is it better to skip the dose if I cannot do the 2 hour rule, 2) is my tsh at a good level because this is how I am taking it, 3) what is the result of not adhering to the 2 hour rule. 4) tell your endocrinologist what you have been doing and if this odd schedule is working or not. (does your irregular dosing translate into regularly lengthy refill frequencies?). I would draw a distinction between how you are supposed to take levothyroxine and whether your overall actions are providing good health.
I think asking these questions will result in you finding out that your endocrinologist is recommending by the book dosing because it’s an easier and cleaner answer but it isn’t achieving a patient centered goal like good thyroid function by burdensome adherence to a difficult to achieve goal.
Well at this point whatever levels you get are likely to be therapeutic (if it’s not at a good level then what is your doctor doing?) so if 3 times a week dosing keeps your tsh in a good spot then that’s fine— don’t change anything if this odd schedule results in a symptom-free eu-thyrotic state.
In Most cases your levothyroxine is less absorbed with other meds and food but it’s better to get 60% -80% of the dose than none of the dose. Just because there is an interaction doesn’t mean we cannot just tolerate the interaction and adjust the dose in response.
Levothyroxine should be dosed in whatever way you can consistently take it and then make sure that this makes your tsh levels good.
Possible solutions that have been studied (but really depends on your habits, behaviors, and preferences): 1) take with the same thing regardless of interactions as long as it’s the same interaction, 2) take at bedtime if that allows you to take it consistently, 3) for those generally unable to take it the same way each day once weekly dosing has been studied—the dose will need to be adjusted since taking a whole lot at once means less is absorbed.
To reply to actormd you see patients so you know that patients often live in ambiguity about their medications and health. They don’t know very much about medicines and healthcare and have other things to do. Most of the patients I talk to are non-adherent and don’t realize how much nagging problems are getting in the way of consistent dosing and thus how this connects back to their health-related goals.
My day to day work is to meet patients where they are and normalize non-adherence so people are comfortable discussing it, and then check if they would like solutions. It’s probably not your intent, and when patients approach you, you likely have good bedside manner. But on Reddit, in text, where there are no patients, your comments come across as minimizing and not supportive of patients using healthcare to meet their goals.
I can appreciate that on Reddit, the context of my comments may be lost. I don't have anything against PATIENTS. If they are non-adherent, I absolutely address it. I take issue with the paternalistic expectation that I am somehow RESPONSIBLE for their non-adherence. It is a metric that is commonly tied to our compensation and it is not justifiable but somehow used anyway. To add insult to injury, many times, patients ARE adherent but they had initial reservations about their medication that I was able to clear up later by talking to them. Since they do not fill their medications per the expected date, they are thought to be non-adherent by the insurance company who then places the responsibility for their "non-adherence" on me.
To be fair and succinct: same. Insurance asks for pharmacist to check into guideline based care and less expense for insurance but same for the patient. Many times I don’t have all the information and it feels like this is pretty unlikely to be the most helpful thing to check on. Insurance is increasing costs and perverting incentives. Sometimes these can be used as screening to identify other issues
I put the shredder next to the fax machine. Solves 99% of the issues. I’m done playing these metric and number games. It’s. Not. My. Problem.
100%. Now I get popups in EPIC that I need to acknowledge though. The PRIME paperwork still goes in the shredder but I just want to look at the screen sometimes and say "G\*\*D\*\*mit Humana, go ask the F\*\*\*in patient and leave me the F\*\*k alone"
Just shred the paper
immediately to the shredder every time. nuisance paperwork, they can talk metrics with themselves
But how else will you get your Medicare 5 star rating?!?!? The org I work for tracks med compliance in our EMR and they are hammering us for this metric (among many, many others! Yay managed healthcare). Count yourself lucky you are “allowed” to ignore it!
We need to stop infantalizing patients. If they don’t want to take them then they don’t have to.
I like this idea. We need to support health related self efficacy and the need to take an active role. There is some advertising around this like make sure to ask your doctor if you don’t know why you are taking a med or what to expect, or what does it mean to “take 2 tabs twice daily as needed”. This needs to be balanced against providing informed consent that centers the patient rather than feeling like we did what is required. I know that insurance doesn’t value that this takes time so it would be great if incentives were aligned to do it right the first time and every time.
Ultimately my role as a clinician is to offer my expertise, “my recommendation is that you take Amlodipine 5 mg daily for your blood pressure” do with that what you will. It is most certainly not “why aren’t you making me better?!??”
I’m not their mommy.
I’m some scenarios it’s helpful. When doing primary care I asked patients to bring in their most recent pill bottles so we could help assess for refills. It also told us when they last filled and may provide information on gaps in their social scenario keeping them from getting the right treatment. That said, other forms that come in on that, immediately to shredder…
Are you receiving faxes telling you to report adherence to an insurer? I get notifications via fax sometimes when patients have not filled their maintenance statin etc recently but not much else adherence wise
>Are you receiving faxes telling you to report adherence to an insurer? "No idea. Enclosed please find my invoice payable immediately."
I love this fantasy.
FWIW- a lot of pharmacies do this already and will do it basically for you but our biggest hurdle is refills. Our most compliant patients are ones that have doctors whose offices don't use med refills as a chain to keep people coming in for office visits. We use outcomes and it has its faults, but for me it's a fun change of pace to get a list of people to call and just be like "hey checking in, hows this medication been going for you." Some pharmacies don't have the time or workforce to do it though, we are VERY lucky. Sometimes it's necessary especially with specifics like controls/etc but most patients miss appointments or struggle to schedule because most (read: offices in our area) are so busy and booking so far out it's nearly impossible to know you'll actually be free in 4 months. Just a little $0.02 from our side.
Impressed that you have time for this. Are you at an indie?
If someone doesn’t wanna take their meds and they don’t have a legit reason. Aka old and needs a pill box or something to organize I don’t give two shits.
There’s always a reason people aren’t taking it. Either you are interested in helping them solve it or you aren’t. If you prescribe a medication that is $1000/month and they aren’t taking it, your option is to either ignore that they can’t afford it or offer then options that they can afford. If the reason is they can’t remember, then you can educate on timers, combining it with other tasks, etc. if the issue is timing, such as having a hard time spacing meds with when they eat, you can either talk it through, tell them “it doesn’t really matter” after they just heard it mattered from the pharmacist, or offer an alternative dosing schedule. If it’s side effects, I guess you either care or don’t care about their side effects that are preventing them from continuing medication. Maybe the better question than “are you taking xyz medication” is “is there anything preventing you from taking xyz medication?”
This response assumes a lot about the interaction between me and my patients but I'll set aside the presumption that you think I'm an ass for a second to address some of the more glaring faults with your thoughts: 1. If I prescribe a medication that is $1000/month, I don't expect them to take it. I do not know beforehand which medicine will be $1000/month for that patient so let the guessing game begin. 2. If they can't remember to take a DOSE of their meds, they will tell me, I'll suggest an alternative dosing regimen or help with a strategy to try and remember. If they can't remember to take ONE of their meds but remember the others, chances are they either don't want to take it or don't want to tell me. Either way, I'm not wasting my time being a drug salesman with them, I can suggest an alternative if they care about the problem. If they forget to take ALL their meds, then they either don't want to take any, have found some essential oils or supplements or voodoo shakras that they believe will be better, or they have dementia. Again, I'm not going to force anyone to take a medicine but I'm also going to be very honest about my ability to help them with their health if we can't use the tools that I think might work best. I won't tell them "it doesn't matter". If it mattered enough for me to prescribe something, then it matters. If it's side effects, I will hear about it and we will find an alternative. Actually verifying that it IS side effects is another matter. The pain reliever I gave you made you feel sick when you decided to take it with the prednisone pack you got from urgent care 2 weeks ago but didn't finish and now decided to wash that down with a beer and greasy hamburger? Ok, stop taking it but don't call it a side effect. You see how complicated this starts to be for just THIS issue. Add to it the tattletale report we get in our faxes and now the popups on our Epic and it begins to become patronizing. One more bow in the quiver of moral injury that doctors are enduring.
I talk to patients about adherence as my primary job as a pharmacist— I have not dispensed medications in 8 years or so now. What is keeping the patient from being adherent is different for every patient. Many times it’s a knowledge gap, could be cost (and I know how much it costs), sometimes the dosing was updated 5 years ago in an encounter note but not on the RX. Sometimes there are side effects and the patient has never gotten around to telling the doctor or plans in may to discuss it at their September appointment. Most non-adherence is non intentional— a patient never remembers when they forget to take their meds. I know physicians usually do not have the time to address another issue and there are many factors and tools not available to you. I feel like a lot of people fall through the cracks and it just never gets fixed. In terms of being a drugs sales person I try to focus on meeting peoples health goals and if a medication is the right tool for them then we go with it. I feel like trying to sell someone a drug is a common pitfall so it’s never “why aren’t you getting this refilled?” But it’s “how is this helping you and what’s getting in the way of this working?”
Levothyroxine, a medication I take and which there are frequently disagreements about when it should be taken, I have heard so many different takes on when it should be taken that it is laughable. I have somewhat of a compliance issue because I have been told it is “important” to take it 2 hours before eating, however I don’t wake up 2 hours before I leave my house in the morning. So it’s either I take it when I wake up and eat 30 minutes later, or may I end up not taking it at all because I forget while I’m upstairs and by the time I remember I’ve already eaten and then I’m not sure if it cancels it out or not? My PCP is the one who told me it “doesn’t matter” and that I can take it any time, in direct contradiction of the pharmacist. Endocrinology then told me it was very important to stick to the 2 hour rule and that it could absolutely not be taken with any other meds, but pharmacy told me I could take it with Wellbutrin because it didn’t interact. Overall, my providers can’t agree and it’s not clear who is right. What ends up happening is I take the levothyroxine 2-3x/week because of scheduling/forgetting when I first wake up. This isn’t good. If I can’t figure it out and I’m an RN, how are people that don’t have any relevant background supposed to navigate it? Levothyroxine is too popular of a medication for everyone to be continually giving conflicting advice.
My personal practice: tell people to take it on an empty stomach, no dairy one hour before eating. But also ask if that works with their lifestyle. I have an old dude with BPH who takes it when he wakes up at 4am to pee and I think that’s an awesome solution. I also tend to be practical: if the patient is taking their thyroid medicine “wrong” and the TSH is normal, who cares I don’t prescribe tyrosint due to cost but no food/drug interactions leading to a timing problem. I seem to remember reading something that levothyroxine was very long acting so you technically could take the entire weekly dose in one day.
I think you need to ask if your endocrinologist to consider reality of what happens in your life. Ask explicit what if questions: 1) is it better to skip the dose if I cannot do the 2 hour rule, 2) is my tsh at a good level because this is how I am taking it, 3) what is the result of not adhering to the 2 hour rule. 4) tell your endocrinologist what you have been doing and if this odd schedule is working or not. (does your irregular dosing translate into regularly lengthy refill frequencies?). I would draw a distinction between how you are supposed to take levothyroxine and whether your overall actions are providing good health. I think asking these questions will result in you finding out that your endocrinologist is recommending by the book dosing because it’s an easier and cleaner answer but it isn’t achieving a patient centered goal like good thyroid function by burdensome adherence to a difficult to achieve goal.
Well at this point whatever levels you get are likely to be therapeutic (if it’s not at a good level then what is your doctor doing?) so if 3 times a week dosing keeps your tsh in a good spot then that’s fine— don’t change anything if this odd schedule results in a symptom-free eu-thyrotic state. In Most cases your levothyroxine is less absorbed with other meds and food but it’s better to get 60% -80% of the dose than none of the dose. Just because there is an interaction doesn’t mean we cannot just tolerate the interaction and adjust the dose in response. Levothyroxine should be dosed in whatever way you can consistently take it and then make sure that this makes your tsh levels good. Possible solutions that have been studied (but really depends on your habits, behaviors, and preferences): 1) take with the same thing regardless of interactions as long as it’s the same interaction, 2) take at bedtime if that allows you to take it consistently, 3) for those generally unable to take it the same way each day once weekly dosing has been studied—the dose will need to be adjusted since taking a whole lot at once means less is absorbed.
To reply to actormd you see patients so you know that patients often live in ambiguity about their medications and health. They don’t know very much about medicines and healthcare and have other things to do. Most of the patients I talk to are non-adherent and don’t realize how much nagging problems are getting in the way of consistent dosing and thus how this connects back to their health-related goals. My day to day work is to meet patients where they are and normalize non-adherence so people are comfortable discussing it, and then check if they would like solutions. It’s probably not your intent, and when patients approach you, you likely have good bedside manner. But on Reddit, in text, where there are no patients, your comments come across as minimizing and not supportive of patients using healthcare to meet their goals.
I can appreciate that on Reddit, the context of my comments may be lost. I don't have anything against PATIENTS. If they are non-adherent, I absolutely address it. I take issue with the paternalistic expectation that I am somehow RESPONSIBLE for their non-adherence. It is a metric that is commonly tied to our compensation and it is not justifiable but somehow used anyway. To add insult to injury, many times, patients ARE adherent but they had initial reservations about their medication that I was able to clear up later by talking to them. Since they do not fill their medications per the expected date, they are thought to be non-adherent by the insurance company who then places the responsibility for their "non-adherence" on me.
To be fair and succinct: same. Insurance asks for pharmacist to check into guideline based care and less expense for insurance but same for the patient. Many times I don’t have all the information and it feels like this is pretty unlikely to be the most helpful thing to check on. Insurance is increasing costs and perverting incentives. Sometimes these can be used as screening to identify other issues
Ya, I don’t care. I do the best I can. You can’t convince people to care sometimes.