INR management through a remote service

[Ambience]

Hello all,

I've been a long-time lurker of these forums and have enjoyed the information that people have provided when I check in from time to time. Well, it finally happened to me. A Cardiologist who was friendly to my self-management over the past three years moved on to a different practice, and my new cardiologist refuses to refill my Warfarin without me using a third-party "coumadin clinic". I'm a tad frustrated as I've been doing just fine with my numbers and really don't want to pay some third-party just to relay information that I could provide myself.

In my search to find someone that will prevent me from getting wrapped up in the nonsensical nightmare of these clinics, I've come across sites like SteadyMD and others, that offer remote services. They are the same price as what my insurance would bill be for a monthly test at a coumadin clinic (I've been testing weekly on my own), I can have a physician on retainer 24/7. I was curious if anyone has gone that route to obtain a warfarin prescription and what your feedback is. I'm otherwise healthy, active, and don't go to the doctors very often. But this seems like a good option to conslidate my prescriptions and not feel like they are being used against me, which I'm feeling highly irritated by. On top of that, I'm beginning to run out of my medication and want to find a solution quickly.

 

[Superman]

I really hate the whole, “I’ll kill you if you don’t do it my way!” approach to INR and heart health many practices seem to take. I’ve had that battle myself.

I’m currently managed by a “Coumadin Clinic”. They haven’t been too bad. I never interact with the Dr. I email my result weekly. They forward the result to the clinic. The clinic calls and tells me my result (which I, of course, knew already). They tell me if they think any changes are needed. Typically not. If they are, I tell them what I already did. They update my chart. I get supplies in the mail when I need them.

We had a rocky start, but I’m sure there are notes in my file now. Haven’t had to bust out the, “I’ve been managing my INR longer than you’ve been alive, so you can put the book away!” - in ages.

 

[dick0236]

I have never used a Cardiologist for INR monitoring. I have always used my PCP. I have self-tested using a service for the past 10+yrs. I test weekly, send my results to the service who passes the results to my PCP who then calls me with instructions, if any. It does seem like a runaround but I do see some rational as well. Your warfarin prescribing doctor wants a third party lab involved in the event he/she gets sued by you or your next of kin for prescribing such a drug without close followup.

The small additional cost to my insurer (Medicare) for the service is a fraction of what a stroke would cost them if I went back to the OLD traditional method of "once per month" office, or lab, visit.

 

[pellicle]

Firstly I'm in Australia, where we are different.

I was curious if anyone has gone that route to obtain a warfarin prescription and what your feedback is.

in the beginning I went to a clinic, then after a year was so annoyed at their lackluster performance I eventually got to the point where I went it alone but did so with keeping my GP (not my cardio) on board with what I was doing. Doctors do know the difference between a patient who's going to do the right thing and a patient who's going to stuff up, not take their meds, cause themselves harm and blame the doctor.

Show yourself as competent and organised and you'll find a doctor who will just ask you what you want, and you can go get it.

I really hate the whole, “I’ll kill you if you don’t do it my way!” approach to INR and heart health many practices seem to take. I’ve had that battle myself.

glad you won!

 

[Superman]

Firstly I'm in Australia, where we are different.

in the beginning I went to a clinic, then after a year was so annoyed at their lackluster performance I eventually got to the point where I went it alone but did so with keeping my GP (not my cardio) on board with what I was doing. Doctors do know the difference between a patient who's going to do the right thing and a patient who's going to stuff up, not take their meds, cause themselves harm and blame the doctor.

Show yourself as competent and organised and you'll find a doctor who will just ask you what you want, and you can go get it.


glad you won!

Thank you, sir! My most recent threatened “no refills”, I used COVID. “You want me to come in, when I’m healthy, and potentially expose high risk patients at your office unnecessarily just so I can get a maintenance drug that we both know is still needed? You’re aware we are pretty much on lockdown for all but essential services?” Got a call from my pharmacy the next day. Ready for pick up! It’s no joke. I’ve heard several say their doctor wouldn’t refill a needed maintenance drug if they didn’t come in for a check up by a certain date or use their preferred monitoring service.

 

[pellicle]

Ready for pick up! It’s no joke. I’ve heard several say their doctor wouldn’t refill a needed maintenance drug if they didn’t come in for a check up by a certain date or use their preferred monitoring service.

whatever excuse works, use it I say

 

[Warrick]

Hmm sometimes I wish I had medical professionals that cared enough to ask my INR ... but then that feeling soon wears off.. I last had a dosing recomendation 14 weeks post op and the only one that asks about my INR these days is my dental hygenist in case I bleed to death from my gums (tongue in cheek)

 

[pellicle]

in case I bleed to death from my gums (tongue in cheek)

gummysharknado

 

[mecretired]

I have had a st Jude aortic valve for 10 years. I absolutely love my cardiologist but my Coumadin clinic sucks. Initially they would only give my 5mg warfarin—-no other mg. I had to split pills and alternate dosage. My cardiologist finally got them to give me 5’s and 1’s. I do weekly testing with my Coaguchek xs. I input results to the Roche website who then sends them to my Coumadin clinic. I have learned through past experience how my body reacts to a change in Coumadin and that my Coumadin clinic always overreacts. So—if I’m only slightly out of range (and I usually know why) I will just report that I was in range. Then I will make any adjustments myself. So basically I’m testing and dosing myself. The reporting is just paperwork that keeps us both happy. Coumadin clinic is available if I need advice/help.

 

[slipkid]

My old cardiologist & his staff SUCKED at INR/warfarin management. If it was up to them they would have me at 7-8x the warfarin dosage on say Mon/Tues then down to like 1 mg rest of the week. Givng me a rollercoaster INR high at midweek trailing off to dangerously low towards end of the week. No concept at all of trying to dose evenly over a 1 week period and if adjusting doing so in small doses each day (unless there would be a significant huge reason to make a sudden change). And unwilling to listen to anything I would try to suggest.

I had to change to my PCP. He understands trying to be as constant/even as possible. I test at home every week then call it in to Roche. They then let him know. I don't hear from him basically at all other than when I see him for a visit. I modify my doses only if radically high/low or if I get 2 high/lows week in row. Have been pretty much steady most of the time anyways.

My new cardiologist asked me who is managing my INR. I just told him my PCP since it seems like he is the type of doc who doe not trust patients to do anything on their own..

 

[tom in MO]

My coumadin clinic used to be free and then started charging. I stopped calling in my results unless I was out of range. Then I stopped calling if I was out of range. They discovered me after about 18 months and told me I must call in at least monthly or they would no longer have me as a patient. I said that seems odd that they'd let me die for $30 a month. I told them I'd switch and use my GP for warfarin therapy, but they told me my GP uses them (same hospital comples...i.e. same insurers). I registered a formal complaint with the practice and they said they'd get in touch.

They listened and said I didn't need to use the clinic if my cardiologist would agree to my self testing and dosing. I had to spend money to meet with my cardio. I showed him my testing frequency and my dosage changes and he said I wasn't doing anything the he wouldn't have done. I told him if it gets out of whack I'd call him. I made the comparison with diabetics who test multiple times a day and will also die if they don't test and dose properly but don't have to call in results and be charged $30 for a dose adjustment. He has a child with diabetes and that comment hit home. I told him I participate in a world-wide forum and many other countries allow for home testing and dosing so his firms practices may be standard in the US but not in the world. He agreed to let me self test and dose. Maybe a tactic like that would help.

Maybe you can follow your cardio to his new practice or find a new one. You might be able to get your internist or GP to write the prescriptions for you too.

 

[Ambience]

Thanks for the dialogue all, it's been great so far. This weekend I've been taking my med doses in 2mg and 1mg tablets since I'm out of my 5mg and the cardiologist refuses to fill my prescription. I'll call my GP today and see what we can get figured out. I'm really disappointed at the medical field these days, no communication at all from my cardiologist after they said they sent a referral to a coumadin clinic. I could be completely out of meds for all they care.

 

[Superman]

Thanks for the dialogue all, it's been great so far. This weekend I've been taking my med doses in 2mg and 1mg tablets since I'm out of my 5mg and the cardiologist refuses to fill my prescription. I'll call my GP today and see what we can get figured out. I'm really disappointed at the medical field these days, no communication at all from my cardiologist after they said they sent a referral to a coumadin clinic. I could be completely out of meds for all they care.

Check with your pharmacy. Usually they’ll give you a few pills to tie you over if you’re working on a refill.

 

[mecretired]

It is more than a little ridiculous that we have to jump through hoops to get life-saving medication. If you’ve been on warfarin any length of time, you probably know more about how your inr will react to foods or antibiotics than a Coumadin clinic does. Each of us might react similarly but not the same. My Coumadin clinic usually overreacts.

 

[pellicle]

Each of us might react similarly but not the same. My Coumadin clinic usually overreacts.

couldn't have said it better myself.

The issue is that they have no skin in the game.

 

[Ambience]

Thankfully my Cardiologist gave me a two week refill. I contacted the clinic they referred me to and they don't allow home testing or remote visits. When I mentioned my concerns that we're in a pandemic and I'm a heart patient they told me how they are being very cautious with in person visits (Also that they do once a month testing, and seemed shocked I was testing weekly). They seemed to be completely oblivious that I have a zero-risk system right now and receiving better services, but when has the US ever prioritized health over money? I told them I wasn't interested in a visit and have contacted my general doc for a virtual consult. I'll see if he will refer me to a test at home service. If I'm going to pay money for this nonsense, I'm going to ask for a service that's at least equivalent to the care I'm providing myself right now. This nonsense is completely frustrating.

If my doc won't do a test at home, I'm going to look into the online provider services. Although they're pricey, they seem to be flexible with certain areas of care.

 

[Superman]

I would recommend getting in touch with your insurance provider. They may already have an approved service that they partner with. You can then take that to your regular doc to get them to write for your prescriptions.

That’s how mine works. My insurance will cover home monitoring, but it has partnered with one company to provide the equipment, testing strips, and that company is where I report my results. They forward my results to me Coumadin Clinic who calls me to discuss if any changes are needed. If I’m in range, often I won’t even get a call. If I’m a bad patient and skip a test, the clinic will call and remind me.

They won’t cover me just buying a machine and test strips and testing on my own. I assume it’s in part for liability reasons. If they’re paying the bills, they want it monitored so I don’t slack and have a very expensive medical event as a result. I mean, they care about my well being.

 

[Ambience]

Superman, thank you for the advise. I'm checking in with my insurance provider now.

 

[tom in MO]

Your insurance company may help you find a cardiologist that allows home testing.

 

[Ambience]

Good news, I had a remote consult with my Primary Care Doctor. He was willing to take over my monitoring with my existing equipment and situation. I will be able to continue my weekly testing and he will handle my prescriptions. The only difference is I'll be sending my numbers to his office weekly for monitoring and adjustment. The main change which is actually better and recommended, is that we will do periodic calibration tests of my equipment compared to IV lab draw. I feel really good about this arrangement and won't have to seek out a remote physician service.