Warfarin Prescription and Anticoagulation Service

[Juli]

My previous primary care physician moved. For over 7 years I was testing at home, she provided the Warfarin prescription and I sent her once a month my test results. The new physician insists that I am working with the coagulation clinic that requests my testing results now once a week and then provides the Warfarin dose for the next 7 days. My experience with this service has been very poor and almost every week I have do deviate and make my own small adjustments. For a few weeks I followed the prescribed schedule resulting in INR levels over 4. I test twice a week (Wednesday and Sunday) which allows me to make adjustments if necessary (I know it is overkill - but why not) which frustrates the pharmacist in the clinic - they think they have to aim for my target INR (2.5 - 3) only once a week.

The real issue that I have with this coagulation clinic is that it cost me $30 each week! - while I buy my own supplies and own my meter. The prescription comes from my primary care physician - but she is afraid to provide the prescription without the involvement of the coagulation clinic and mentions insurance.

I am ok paying the test strips (about $500 per year) - but now combined with the coagulation clinic “service” this comes to $2000 that I am forced to pay. I am not sure how to get out of the situation and also feel insulted after 7 years of successful self management. Also starting November I will be on Medicare - not sure what that will do to the cost.

All I need is to find someone to provide the Warfarin prescription - the rest I handle myself. How do others get this solved?

 

[Protimenow]

If it was me, I'd find a different doctor.

My PCP prescribes the warfarin and trusts me with my self testing and self management.

My cardio also trusts me to self test and self manage.

I don't see how you're somehow LOCKED to this particular physician.

Plus, if they mess up and prescribe dosages that you know don't work, what good are they to you?

At one time, when I had no doctor and no money to get one, I bought my warfarin from a pharmacy in India. Same stuff as what you get in the United States - no prescription needed, and they cost about a dime or so a pill.

 

[pellicle]

Hi

All I need is to find someone to provide the Warfarin prescription - the rest I handle myself. How do others get this solved?

well I know this works for me, and I know "at least" one other American who does similarly.

When I need to get a new doctor I take my spread sheets on a tablet (iPad if you're unfamiliar with generic terms) and show them what I do (in a general way) and my records (with nice graphs) of my dose and INR results of my weekly testing and then explain my self management regime.

The primary reason why most doctors don't want to get involved seems to be that they have:

1. zero understanding of how it works
2. are terrified that its a nightmare to manage warfarin
3. don't want to be involved

So if you show yourself to be a well organised, regimented and (above all) ACT compliant patient, you will find they are very happy and will hence forth be happy to just write scripts. Further if you back this up with occasional blood tests in house (for say typical blood panels like liver function) and include INR, they'll get to see themselves you're INR is in range.

That's what I recommend. Reach out if you want a system of how do to that using Google Sheets.

 

[3mm]

starting November I will be on Medicare - not sure what that will do to the cost.

Juli - I am on Medicare. I have a Medicare part G supplemental from AARP (United Healthcare). It costs $149.80/month. I think the deductible is $300/year, after which most everything is covered. Since I met my deductible this year, I never get a bill from my coagulation clinic. It is completely covered by my Medicare and Medicare part G. They also issued me a Coaguchek XS meter, so I self test and use a phone App to report my INR. I paid nothing for the Coaguchek, and I pay nothing for the phone App. When I need test strips for the meter, I order them through the phone App. I pay nothing for the test strips after meeting my deductible.

Also, when I had my open heart surgery last Sep, I never even got a bill from Mayo, because it was completely covered by Medicare and my United Heathcare part G Medicare supplemental insurance.

So look carefully at Medicare, Medicare part G supplemental plans, etc. I am not an expert, but ping me if you have questions.

I use Pellicle's google sheet for tracking my INR and determining Warfarin doses. I use it to check the Coagulation clinic proposed daily doses. Since my INR is normally very stable, Pellicle's sheet normally proposes a dose that is consistent with the Coagulation clinic's prescription. This is reassuring, and helps me sleep well.

When I was recovering from Pneumonia the google sheet disagreed with the Coagulation clinic's prescription, so I did what was best for me. The Coagulation clinic is very hesitant to change a dose by more than about 7% each week. Sometimes a dose should be changed by 10% or even 12% for a week or so IF the INR is way out of range. I didn't bother the Coagulation clinic with temporary deviations in doses, and after a couple weeks everything was in agreement again.

 

[Juli]

Thanks - very good advice.

 

[Protimenow]

3mm:
I was toying with the idea of using an 'anticoagulation clinic' to provide me with the machine and strips. I was concerned that the insurance pays a LOT for this 'service.' What put me completely off this clinic is that they don't allow for extra strips --- if I made testing errors (wasting strips) or needed to test more than once weekly, I would have to buy strips.

I buy my strips anyway. I chose NOT to go with an 'expensive' service, basically, to get a loaner meter and a somewhat limited supply of strips

 

[tom in MO]

You are using a primary care physician for warfarin therapy. You might want to try your cardiologist. Their office could tell you what they do. A cardiologist is more experienced with warfarin therapy and also things that can effect your INR than a pcp.

My cardio's practice uses a service, but I am not on Medicare and they charge $30 a pop and my deductible is 750 with a 25% copay. So I asked my cardiologist if I could do it alone and save money. I used diabetics as an example, they don't call to change doses. He agreed to monitor me as an individual outside their clinic with two restrictions. My range is 2-2.5 and if I go 0.5 point out of range, I have to call and tell his nurse what I did to fix it. The second restriction is I need to bring in a copy of the INR results since the last time I saw him so he can see my history and demonstrate compliance to his warfarin therapy.

 

[Protimenow]

tom in MO: We've gone over this before. I'm glad to see that the bottom of your range is NOT below 2.0, but I still think you should aim more for 2.5 - 3.0 than 2.0 - 2.5. Because meters (or lab tests) aren't always 'accurate,' a lab or meter score of 2.0 might be more like 1.6 or 1.7. This may be a somewhat risky value - even with an On-X valve. You might want to discuss changing your range to one that's slightly higher.

 

[Lisa from LJ]

How often does your PCP want you to test? Do they insist that you check in weekly because you told them you test twice a week? If so, I would tell them that I'd decided to only test once a month. Keep testing as often as you want, adjust as needed, check in once a month, and you only have to pay $30 once a month. Speaking of the cost, do you have insurance and are they submitting the claim to insurance? Does your insurance say that's how much you owe? The code they should be using is reimbursed about $12 by Medicare. Other payers could be higher or lower, but they should be billing insurance and you should only be paying what the insurance says. I had an issue with a previous doctor years ago where they tried to charge me $10 for "monitoring my results." I was going to a national lab for a blood draw and they did the test. I insisted that they file with my insurance and I'd pay per their contract. Ends up that insurance said the code was non-payable so I should pay nothing. Again, it's different based on the payer.

My physician requires me to check in monthly with the Coumadin clinic because of potential malpractice issues, but allows me to tell them what adjustment I'm making or made (I test every two weeks). There is no charge.

 

[tom in MO]

tom in MO: We've gone over this before. I'm glad to see that the bottom of your range is NOT below 2.0, but I still think you should aim more for 2.5 - 3.0 than 2.0 - 2.5. Because meters (or lab tests) aren't always 'accurate,' a lab or meter score of 2.0 might be more like 1.6 or 1.7. This may be a somewhat risky value - even with an On-X valve. You might want to discuss changing your range to one that's slightly higher.

Thank you for your concern. However, I have on several occasions dropped my warfarin and went to INR of 1 for procedures. There were no adverse events. My range has been vetted by 2 cardiologists and my surgeon. I have no fear of being at 2-2.5 especially when I've dropped to 1 without a problem. That's the beauty of a St. Jude mechanical valve in the aortic position, it's "robust."

 

[Protimenow]

I've dropped my INR below 2 - approaching 1 - and have had no issues either - but I brought it back up as soon as I could, by starting my standard dose after a procedure. It takes a while for a clot to form on the valve - a few days shouldn't be a big deal. If you or your doctor are really concerned, you can bridge with injectable heparin.

 

[Juli]

How often does your PCP want you to test? Do they insist that you check in weekly because you told them you test twice a week? If so, I would tell them that I'd decided to only test once a month. Keep testing as often as you want, adjust as needed, check in once a month, and you only have to pay $30 once a month. Speaking of the cost, do you have insurance and are they submitting the claim to insurance? Does your insurance say that's how much you owe? The code they should be using is reimbursed about $12 by Medicare. Other payers could be higher or lower, but they should be billing insurance and you should only be paying what the insurance says. I had an issue with a previous doctor years ago where they tried to charge me $10 for "monitoring my results." I was going to a national lab for a blood draw and they did the test. I insisted that they file with my insurance and I'd pay per their contract. Ends up that insurance said the code was non-payable so I should pay nothing. Again, it's different based on the payer.

My physician requires me to check in monthly with the Coumadin clinic because of potential malpractice issues, but allows me to tell them what adjustment I'm making or made (I test every two weeks). There is no charge.

Very good advice, just messaged my PCP and the anticoagulation clinic. I do have insurance and my co-pay causes the $30 per “visit” which in reality is sending a message through MyChart. I am not sure if they even bill my insurance and will follow up - but I am afraid that the co-pay is the problem here. Thanks for your input. I may have to look for a different PCP - my previous PCP required the same as your current physician - which worked for over 7 years at zero cost and I saved almost $11,000.

I am concerned that we with a mechanical valve are revenue targets for Roche and anticoagulation clinics. I am also worried that some day Roche might decide that the business with the meter and test strips is not profitable enough and decides to discontinue the product line.

 

[perrybucsdad]

I use Pellicle's google sheet for tracking my INR and determining Warfarin doses.

Can you or someone tell me where I might find this Google Sheet? I wrote a small program as well some years back and want to see if this might be better than how I do my tracking.

 

[MdaPA]

Can you or someone tell me where I might find this Google Sheet?

See thread in below link:

https://www.valvereplacement.org/threads/remoteinr-alternatives.889310/post-928267

 

[perrybucsdad]

Thank you!

 

[3mm]

Can you or someone tell me where I might find this Google Sheet?

Pellicle is very active here; however, being Australian, he sleeps during .... our American day. If he doesn't respond to this thread, just start a conversation with him. He's easy to talk with, and he has helped many of us with his spreadsheet.