Hospice Patients Alliance: Consumer Advocates

When Getting Prescriptions Filled,
Beware of Medication Substitutes!

With every passing day, we hear of more ways that HMOs, managed care organizations and other health insurers are acting to cut their costs by cutting services or supplies provided to the patients they are supposed to serve. Hospice patients and their families must also be vigilant to make sure that they receive the medications which their physician has ordered ... not just a substitute that the HMO, managed care organization or even the hospice substitutes to save them money, possible placing you or your loved one at risk.

There may be several types of medications available to treat any particular disease or condition. Your physician is the professional most knowledgeable about which medication is best for you or your loved one. When the physician chooses to order a medication, it is because he or she knows your particular condition, history and how you have responded to medications in the past. For example, one medication may control high blood pressure very well, while another similar medication may completely fail to do the job. Substituting the cheaper medication may make dollar sense to the health insurance company or hospice, but it could be deadly for you or your loved one, ... and the physician is the only one with the authority to prescribe medications: not the HMO, not the managed care organization, and not the hospice!

How this applies to Hospice Patients

When your physician wrote prescriptions for health conditions or diseases which your loved one has, it was mostly likely done with careful consideration of many factors specific to the case. A patient that enters hospice for a terminal illness may have other conditions or diseases besides the "terminal illness." For example, a patient with congestive heart failure may also develop a terminal cancer. Hospices are responsible to pay for the medications related to the terminal illness out of whatever reimbursement they get for their services (minus up to a 5% copay/maximum of $5.- per prescription). The hospice is not responsible to pay for medications which are not related to the terminal illness.

In the example above, the physician who ordered medications for a patient with congestive heart failure knows the patient's condition and history. Just because a terminal cancer has been diagnosed, does not mean that the medication for the heart condition should be stopped. Stopping all other medications (for non-terminal conditions) can hasten death and cause severe problems and symptoms.

Hospice is not about hastening death, but about providing proper comfort care. Medications for non-terminal diseases are normally continued all the way up until the end, when the patient is so close to death that taking those medications is more of a problem than a help.

Hospices may sometimes choose to try to change a patient's medications. This could be done for several reasons. Sometimes, it is simply because the patient is close to death and does not need those medications. But even if the patient is not close to death, some hospices still choose to try to have the medications changed. You do not have to accept those changes. The hospice does not pay for those medications, and you can choose to have those continued. Even if you are enrolled in hospice, if you have private insurance, you likely still have coverage for non-terminal illnesses through that health insurance. If the hospice suddenly "pulls" all your medications related to non-terminal illnesses, call your physician and ask him directly if that is his wish and doctor's order. You do not have to allow all medications to be pulled. You do not have to allow medications to be switched against your will.

In many cases, your physician may not be aware of all the changes the hospice is making or may not be fully aware of your actual condition. In some cases, the hospice may claim that your loved one is "declining" and doesn't need these medications any more. If that is the case, and your loved one is actually very close to death, it may be appropriate to withdraw all medications, except those which provide comfort and manage symptoms for your loved one. But again, that is for your physician to decide, not a hospice agency, nurse or pharmacy.

What About if the Medication Being Switched
is for the Terminal Illness?

If your physician has ordered specific medications to control symptoms related to your loved one's terminal illness, and the hospice all of a sudden wishes to substitute other medications, you need to ask questions. Is the new medication more effective than the one your attending physician originally ordered? Is the new medication cheaper and is that the reason it's being changed? If the new substitute medication is effective, then there is no problem. If however, the new substitute medication does not provide the results desired and your loved one's symptoms are not properly controlled (or worse), then you need to let your physician know about that. You will need to discuss these questions with the hospice RN case manager. If you don't get a prompt reply that satisfies you, then call your attending physician.

What to Do If the Hospice Refuses
to Switch Back To the Better Medication

Hospices may be within their rights to substitute equally effective medications for a prescription originally ordered by your physician. However, your physician must approve the switch, because no medication may be dispensed without a physician's order. If the hospice refuses to provide medications which actually do provide effective symptom management and relief, then the hospice would be in violation of a basic condition of hospice care: the hospice must make sure that their patients' symptoms are managed as well as possible and that your loved one is kept as comfortable as possible. This means that, according to the regulations, all medications necessary to meet the needs of your loved one must be provided.

When the result of a medication switch is uncontrolled symptoms, then the hospice is out of compliance with the standards. You can discuss this with the RN case manager and the hospice director. If no prompt changes are made, the hospice medical director is obligated to act on your behalf. If not, you can file a complaint with the State and other regulatory agencies and provide the hospice with a copy. You can switch hospices, or you can choose to pay for the medication yourself and work out reimbursement from the hospice later (that would be the last option recommended).

Physicians may be Rewarded For Doing Less

Sad to say, but in some cases, the physician may be ordering medications according to direction from the health insurance plan and not according to what is best for your loved one. Physicians are rewarded with substantial financial bonuses when they cut HMO or health insurance plan costs. The reward can amount to tens of thousands of dollars or more.

Consider the following actual case of two physicians in the same group practice, both who saw an equal number of patients last year. One physician complied with all HMO requests, cut costs and ordered only the medications and lab tests approved by the HMO. The other physician ordered only the medications which she believed to be the best for the patient and insisted on ordering all tests needed to provide proper medical care for her patients. She fought the HMO, argued on behalf of her patients and saved many of their lives by doing what was right.

Who got the most money at the end of the year? The doctor who complied with the HMO wishes and provided the least care! He earned $140,000 last year. The doctor who did everything for her patients and saw an equal number of patients as the other doctor got $65,000. And the physician who received the $65,000 by doing the right thing for her patients is now considering leaving the medical profession! HMOs and managed care are destroying the medical profession by rewarding physicians who do not provide the best services for their patients and by punishing those physicians who do provide the best services for their patients.

So in some cases, it is no longer safe to assume that even your physician will always be doing what is best for your loved one. You've got to become knowledgeable about your loved one's condition, needs and why each medication is given. We have received complaints about some hospices requiring their patients to switch physicians when they enrolled in hospice; the hospice had all patients signed up to use the services of the hospice physician. This is completely inappropriate. In no case should you have to switch from your attending physician to the Hospice's own medical doctor just because you enroll in hospice. This is not a requirement of hospice. You have a right to keep your own physician when you enroll in hospice.

Substitutions for Medications
Occur In many Health Care Situations

Substitutions of medications ordered by your physician may occur in many areas of health care: hospitals, nursing homes, HMO health centers, pharmacy, home care and hospice. You need to be vigilant and if necessary, assertive to make sure you or your loved one get the medication that is needed for the illness being treated. For example, some patients have been denied specific forms of medications for asthma or diabetes and had their lives endangered when substitutions of medications were made against their physician's original orders. Being aware of the problem and asking pertinent questions can protect your loved ones. In hospice care, being vigilant and asking questions can help your loved one have a death with dignity and reduce unnecessary suffering.

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