Is 90 Days Too Little or Too Much?

When I wrote my original piece discussing the prescription policy of the free clinics, my primary concern was for patients without adequate access to transportation. I argued for increased scrutiny into the policy because these patients might have been better served with longer supplies of prescriptions. Ultimately, I suggested that implementing better collaboration between the clinics would be a great first step to addressing the larger issue.

In that piece, I did mention the potential for prescription abuse. One form, I explained, was that “patients can game the system, traveling from clinic to clinic to obtain duplicate prescriptions.” While this was not backed up by any specific examples, it was based on anecdotal evidence from my conversations with the clinic leaders and other medical professionals at the clinics.

One form of prescription abuse that I overlooked is the risk of suicide or overdose due to an excessive amount of prescriptions. This is particularly true with psychiatric medications where patients are already at heightened risk. Brian Barnett, in his piece, “The 90-Day Prescription Isn’t for Everyone,” provides a succinct rebuttal to the idea that patients should be given longer supplies of prescriptions, emphasizing that “psychiatric drugs play an outsize role in intentional overdoses.” Therefore, like in the free clinics, he explains that “prescribing conservative quantities to these patients is standard practice” (Barnett 2019).

Do the free clinics follow this same ideology? I wanted to investigate this issue and determine if there is a difference in the number of days of medication given out for psychiatric prescriptions versus others at the Epworth Free Medical Program.

For each instance of a psychiatric prescription between 2014 and 2019, the daily intake of pills, number of pills, and number of refills was recorded. The total daily supply was calculated by dividing the number of pills by the daily intake and multiplying by one more than the number of refills. This resulted in a new metric describing the total number of days of medication prescribed to patients.

total_supply = num_pills / daily_intake * (num_refills + 1)

These calculations showed that, on average, providers prescribed 42.9 days worth of psychiatric medication to patients. The breakdown of days by prescription is shown below.

In the future, it would provide an immense benefit to analyze the data in greater detail. For example, we can examine “at risk” patients, defined as having a chief complaint of psychiatric nature or diagnosis of psychiatric nature.

I think this issue warrants extensive discussion to determine the best practice for the free clinics. Maybe the policy currently in place is already the best practice in consideration of these points and those I raised in the earlier piece.

At the end of the day, the general consensus amongst the physicians and providers at the free clinics is that patients should not be given more than 90 days worth of prescriptions. Ultimately, patients should follow up to review their prescriptions, get additional treatment, or get a primary care provider. This should be made easier for patients struggling with transportation Potentially, the clinics can help subsidize a mail pharmacy so patients in need can get their prescriptions through the mail, don’t have to keep picking up new ones, and get only a limited quantity at once.

Note: the fully anonymized data is obtained from an IRB-approved research project at Worcester Polytechnic Institute, under the direction of Brenton Faber, PhD.

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“The 90-Day Prescription Isn’t for Everyone,” by Brian Barnett, February 6, 2020. https://www.wsj.com/articles/the-90-day-prescription-isnt-for-everyone-11581032892

“Prescriptions and Policy in the Free Clinics,” by Sahil Nawab, December 30, 2019. http://www.sahilnawab.com/wfcc/q4_2019.pdf

“Top 25 Psychiatric Medications for 2016,” by John Grohol, July 8, 2018. https://psychcentral.com/blog/top-25-psychiatric-medications-for-2016/

Prescriptions and Policy in the Free Clinics

Note: This article was originally published as part of the Q4 2019 issue of the WFCC Newsletter and is reproduced here with permission. See original: http://www.sahilnawab.com/wfcc/q4_2019.pdf

Part of human nature is to make assumptions about others. This cognitive heuristic, while somewhat valuable in the past, now simply perpetuates ideals that are no longer relevant to modern society. When analyzed from the collective perspective, that is, by looking at systematic prejudices in institutions and professions, we can begin to tease out the less visible, but often more subversive prejudices that impact people at the population scale. This is particularly true in medicine, where the impacts of these institutional assumptions disproportionately harm those who we seek to help in the free clinics.

In this piece, I want to examine the prescription policies in place at the free clinics and invite discussion about the various factors in play. With that said, this is only a first step in addressing this complex issue rife with nuance. No amount of standardization can remove the necessary professional judgement of physicians and healthcare providers, but this may be an area where healthcare policy can make a tangible impact in patient care for the uninsured patient population in greater Worcester area.

The standard protocol encourages providers to prescribe the minimum necessary amount of medication. In practice, this often results in common chronic disease prescriptions being written for 30 days during the first visit, bumped up to 60 days on a following visit, and a maximum of 90 days on all subsequent visits. This procedure is grounded in real concerns – most prominently the potential for prescription abuse. However, it leaves the most vulnerable patients in limbo.

Uninsured or underinsured patients suffering from chronic diseases, such as diabetes or hypertension, are often the ones that have the most challenges associated with physically accessing prescriptions. Lack of transportation and difficulty taking time off from work during working hours are primary contributors to patients skipping their medications, along with insufficient funds to cover the prescriptions. These diverse issues cannot be solved without a large scale political effort and potentially restructuring the entire employment scheme. Regardless, being aware of these fundamental issues is vital to effective policy proposals on the part of the Coalition and the individual clinics.

Providers are rightly concerned that patients can game the system, traveling from clinic to clinic to obtain duplicate prescriptions, especially in light of the opioid epidemic. Despite this, a more benign, yet potentially even more subversive justification for the policy is the idea that the clinics are simply stop-gap measures rather than primary care facilities and provide care to any person without question.

On the face of it, the answer is simple: the clinics are not, in fact, primary care facilities. A better analogy might be that of urgent care centers, but even this falls apart because the clinics do not have the staff, equipment, or funding to address more serious illnesses. The clinics are simply not equipped to provide the long term, personal care that is required of a primary care facility, nor are they equipped to provide immediate care for the types of injuries and illnesses that urgent care centers treat. Patients inevitably still end up using the clinics for both primary care and urgent care.

Keeping in mind these conflicting messages, that the clinics provide care to anyone without question, and that they are neither primary nor urgent care facilities, updates to the standard operating procedures need to be made to better address the dichotomy. Without these changes, patients will remain in limbo, especially those looking for long term prescriptions for chronic illnesses.

Currently, 28.2% of patient encounters at Epworth result in the patient receiving one or more written prescriptions. A full 10.1% of patients arrive at Epworth seeking prescription refills. Providing prescriptions that take into account patient transportation challenges may be addressed by, for example, encouraging prescribing physicians to ask patients about the accessibility of prescriptions.

Another suggestion might include updating the standard operating procedures at the clinics to enable cross referencing of prescriptions, especially for some medications that are more prone to abuse. This does not reduce the importance of professional judgement, but rather reduces biases and provides objective measures that can ultimately lead to better patient care. An even more ambitious solution, but one that might address a larger range of the issues that the uninsured and underinsured population faces, is creating a mobile pharmacy that travels to each of the clinics. Patients can pick up their subsidized prescriptions immediately, while they are already at the clinic without need of further coordination. Even just having pharmacists available to discuss prescriptions during sign out may be immensely helpful to get patients to understand complex medications, their side effects, the proper time frame to take them, and answer any lingering questions.

Coordinating between the multiple bastions of healthcare falls more and more on the patient. Rather than institutions playing this vital role, increasingly patients are responsible for making the phone calls to get prescriptions, understand the side effects, and ensure that they can afford the medication.

This makes a strong case for increased collaboration between the clinics, especially for prescriptions that have higher potential for abuse. Yet while the proposal for a system-wide EMR has yet to gain the full support of the Coalition for a variety of reasons, significant strides have been made thus far in bringing the individual clinics together. Careful policy that balances these multiple factors, on the part of the WFCC and individual clinics, can help defray the costs associated with being uninsured or underinsured in the greater Worcester area.

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“Unpaid, stressed, and confused: patients are the health care system’s free labor,” by Sarah Kliff, June 1, 2016. https://www.vox.com/2016/6/1/11712776/healthcare-footprint.

This article describes “the considerable burden our fragmented system puts on patients to coordinate their own care,” and how the challenges associated with dealing with multiple systems in person and over the phone to get prescriptions can be akin to a part-time job.

When Clear Writing Really Matters

I know that this is certainly quite late — I had saved this article a few months back and am only now getting to writing about it. Nonetheless, I think it is valuable enough to warrant another look.

When the report, and Rozenweig’s ensuing article, first came out, it reminded me of the importance of brevity and directness. In science writing, conciseness and clarity are prized. However, in the pursuit of objectivity, we often use the third-person passive voice, and this style has deeply impacted my own writing. I now resolve to use more active verbs to provide narrative and agency to the words on the page and to show responsibility of actions.

On a whim, I took a class about teaching writing, and it taught me quite a bit about the pedagogical philosophy of college-level writing instructors around the world. In particular, I developed my own ideas about what writing is supposed to be, what purposes it is supposed to serve, and how my own particular style of writing fits in amidst a great variety of different forms of communication.

This class was invaluable, and I encourage anyone who has the chance to take such an opportunity because, “some day they may have something to say that really matters to them and possibly to the world — and they will want to convey it when the moment arrives in writing that’s clear and concise” (Rosenzweig 2019).

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“The Whistle-Blower Knows How to Write,” by Jane Rosenzweig, September 27, 2019. https://www.nytimes.com/2019/09/27/opinion/whistleblower-complaint.html