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HMO puts clamps on pain meds New rules, made to curb abuse, shock patients By SUSAN JAY Debbie Swanson, a single mom suffering from fibromyalgia, has been trying to get her prescriptions refilled since last week. If it doesn't happen soon, she'll be without muscle relaxers. That means the Medford resident won't be able to move, which means she'll have a hard time caring for her 9-year-old boy by herself. Tracey Long hasn't been able to get his prescription for pain medication filled, either. Two herniated discs in his spine are causing sharp burning that runs down his left side, leaving him sometimes unable to walk. Long lives in a Medford foster home and is a Jackson County mental health patient suffering from severe depression. All the members of his family have died in the past two years. Swanson and Long are among the thousands of Oregon Health Plan patients trying to jump the new hurdles added by their HMO, Family Care, which is trying to cut pharmacy costs by using generic drugs and restricting the use of narcotics and muscle relaxants. "It's frustrating to the point of tears at times, and I don't cry easily," Swanson, 40, said. She was a health care administrator at Providence Hospital in Alaska, before her fibromyalgia hit five years ago. When her pharmacist told her last Thursday she needed a preauthorization from Family Care to refill her prescriptions, she was flabbergasted. "It's not the insurance's right to tell us how much medication we can take," she said. "It's the physician's right." Family Care officials say something had to be done to curb the drug abuse they are seeing, but local patients and health care providers criticize the HMO's method, saying people are going without their pain medication and there has to be another way. "The problem is that our pharmacy utilization for narcotics and muscle relaxants is way out of control," said Jeff Heatherington, chief executive officer of Family Care. "The number of pills being prescribed throughout the state system amount to five tablets a day per patient," he said. For example, Heatherington said one Jackson County couple with multiple medical complaints "that wander all over their body" is responsible for $9,000 of narcotic prescriptions in the first eight months of 1999. "That's the kind of abuser we're trying to get a handle on," he said. Family Care, which covers an estimated 8,000 Oregon Health Plan patients in Jackson County, implemented the new restrictions in all 10 counties Sept. 15. The HMO has said it is strongly considering leaving Jackson County, but is negotiating with PrimeCare, which represents more than 250 local doctors, on a new contract. In the meantime, Heatherington said that every HMO member who legitimately needs pain medications and muscle relaxants will get them. A preauthorization is required from the HMO for every prescription of pain meds and muscle relaxants. Pharmacists can give only 30 capsules or tablets per prescription every eight weeks. Anything prescribed before then also requires a preauthorization. These preauthorizations take time. They require a doctor's explanation for medical necessity and the HMO's approval. Patients with cancer, a terminal illness or chronic pain and those just out of surgery are exempt from all requirements, except the first pre-authorization. Patients in nursing homes, foster care homes and other institutions already are supposed to have preauthorization, while Family Care reviews their medical need. "We are also concerned that physicians need to be more diligent in their prescribing of narcotics," Heatherington said. "First, to make sure the patient isn't getting other prescriptions from other places." He said Family Care knows some of the HMO's members are getting narcotic prescriptions from multiple sources -- including dentists and other doctors -- and that their primary care doctor probably doesn't know about it. Heatherington admits the HMO could have done a better job with adding the new requirements. While Family Care did notify the doctors and other health care providers, "we didn't notify the pharmacies, which was a mistake on our part. There have been some rough spots." Dale Smith, a pharmacist for Evergreen Pharmacy, said they found out about the new process when all their prescriptions for nursing care and assisted living patients came back rejected. "We sent out the medication whether Family Care said so or not; I mean we're committed to these people. We can't just let anybody hurt," Smith said. Heatherington said Family Care has received the list of 100 or so patients from Evergreen and that the pharmacy will have authorization to fill prescriptions, while the HMO reviews the cases. The HMO also didn't notify its members, for fear an announcement would mean patients would stock up on their refills. Hersh Crawford, the director for Oregon Medical Assistance Programs, said they just received Family Care's notice of requirements and have been trying to contact Family Care's medical director, Arthur Rott. "We need a better understanding of exactly what Family Care is trying to do with these guidelines," Crawford said. "Ultimately, if there are things here we think are not appropriate, we'll have to discuss them." Peg Crowley, executive director for the Community Health Center, said Family Care is testing its hypothesis that doctors over-medicate. That isn't good medical practice, she said, adding that Family Care will find that local doctors are conservative. "I don't like the process," Alan Bates, a Central Point physician, said of the new restrictions. "I think it's ridiculous." He is concerned about Family Care's losses in pharmacy usage, but called this method a "knee-jerk" reaction to the problem. "I think we're going to have some patients ... who are going to be hurt by this." Lisa Bailey, medical director for Jackson County Mental Health Services, saw Long when he was upset over not being able to refill his prescriptions. "My take is that the cost of medication has exploded," she said, "not just for pain meds, but for all meds, and the fully capped HMOs are looking at any mechanism possible to restrict the cost." Mail Tribune Copyright � The Mail Tribune 1999, Medford, Oregon USA