Cheeseburger, Cheeseburger. No Coke, Pepsi.

Twice in the last month I have written prescriptions for triple therapy to treat H. Pylori in Alaska Medicaid patients. Part of this therapy is a medication called a proton pump inhibitor (PPI) . The available drugs on the Medicaid formulary are Nexium (esomeprazole) and Prevacid (lansoprazole).

I choose Nexium for H. Pylori therapy because it is FDA approved for single daily dose in the treatment as opposed to twice a day. It should cost half as much. The problem is Medicaid will not give any patient a PPI without prior authorization despite formulary status.

On both of these occasions I was outside my office. I do not make a habit of carrying around a pre-authorization form. It might not matter because when I called on one of these cases a local pharmacist told me it can take a week to get the approval from Medicaid.

The Medicaid pharmacist I reached after 4 phone calls and 45 minutes of phone menus vigorously denied that claim and told me approval should happen right away. The truth from observation is usually somewhere in between.

The danger in both of these cases is that the antibiotics were actually distributed to the patient without the PPI. One of them at least was taking over the counter omeprazole albeit at a dose not used for H. Pylori eradication. The other was able to get Nexium samples from my office a few days into treatment. Either way, the substandard PPI dose can lead to a lower eradication rate.

Medicaid is not alone. The insurance for one of the big hospitals in town refused to authorize a PPI for an ulcer patient of mine on discharge from the hospital. The patient went a week without a PPI. That is even more risky because PPIs have been shown to reduce the risk of re-bleeding in ulcer patients.

Medicare part D plans are not even worth calling or filling out forms. Most of them will flat out not give patients many medications regardless of indication.

The VA is notorious. At least they will give generic omeprazole without an encyclopedia of information. They, however, do interfere with bowel prep medications for colonoscopy, medications for Inflammatory Bowel Disease, and a few other things that give my office headaches.

Many times deals on medications have been reached by insurers and it is a cost saving process. It makes sense except when entire classes of drugs are not available. There are at least a half a dozen pre-authorization forms a day on my desk and I can only imagine what primary care physicians face.

Issues arise when a specific drug in a class is the only one that is clinically indicated. Issues can also arise when an insurer insists a patient use a drug in another class instead.

The pharmacist who I spoke with involved with Alaska Medicaid could not tell me how much they pay for a Nexium capsule. Full price, the drug can cost about $4. A 14 day course might run $56. By the time the doctor, the office staff, the pharmacy staff and the people in authorizations spend the time and push through the paperwork the $56 that will not be saved anyway when it gets approved has already been wasted. Only now, the cost is likely pushing $100 with all the extra work.

There are medical offices in the lower 48 that have a full time employee who does nothing but drug pre-authorizations. It can be a major expense to deal with the issue. This is also one of the reasons insurance companies spend so much money on overhead. It costs a lot of money to hire people to deny prescriptions.

The insurance companies are always changing lists and it is nearly impossible to keep up with on a regular basis. Medicaid has changed its PPI a number of times before they just decided to block any and all prescriptions for them.

Fear not though Alaska because Senator Mark Begich has said a dozen times in the last week that he believes negotiating drug costs is a big part of the solution. He has even said that the Veteran's Administration is an example of how it works. The gastroenterologist sitting next to me at the physician meeting (Dr. Doug Haghighi) nearly had a seizure when Begich said it a week ago.

Really Mr. Begich? You might have been able to hide information from the assembly (allegedly). On this one though you cannot hide what happens every day. It would appear the potential limitations on care are on no concern to the Senator.

There are literally thousands of examples of problems when you have limited formularies when deals are reached. It would be one thing if you had reasonable people controlling the process. Unfortunately, the people running the process are not on the front lines taking care of patients.

There are savings to be had without a doubt. That has to be balanced against the cost to the providers and patients on the other side. Paperwork, time, and worst of all bad outcomes because a treatment is delayed are real issues.

The public has been brainwashed into thinking physicians blindly write prescriptions because a pharmaceutical representative brings lunch. Lunch is about all they bring now because pens and other toys have been outlawed.

I try as hard as I can to put patients on generics. I carry the $4 Wal-Mart list (matched by many competitors) in my coat pocket. I scan prices for just about everything when I go into stores. I use the cheapest effective available treatment available and make it fail before I try something else. I hand out pharmaceutical coupons from my office if I am writing a prescription. I do as much as I can to save patients money.

Most of all I make decisions based on medical evidence. I will write for a different drug if it will save money and offers the same benefits. That is nearly always the case with PPIs. There are times though when I need my patient to have a specific drug.

It is okay to challenge a clinical decision. It is not okay to have the final decision made by a clipboard carrying bureaucrat on the other side of a phone line.

I invite every nurse, pharmacist, and especially the occasional knucklehead physician on the other side to come evaluate my patient and reach a clinical conclusion. None of them has ever taken me up on the offer. They also usually do the right thing because they know it likely took significant effort and time for me to involve myself. It should not have to come down to that.

Mr. Begich's support of drug price negotiation as a solution is very telling. What goes on with these decisions and the formularies it creates are the very definition of rationing. It happens around the world where certain drugs and treatments are simply not made available because of cost.

Now, there are plenty of other issues related to drug costs. There is also volumes of misinformation being spun on all sides of the pharmacy issue. All topics for another day or discussion below.

Listening to Begich the other night for the second time in a week confirmed my worst fears. The politicians in DC have no idea what they are talking about. They only know what the lobbyists from their biggest supporters are telling them. This was only one of the things Begich was spouting that had me shaking my head.

We can only wonder what is in the paperwork Begich is not showing us this time (alledgedly).