Dr Reese - Ethics...??

[ukjoe]

I was in about a week ago to see Dr Reese about some areas of my donor scar which were not healing and that I had removed 3-4 sutures myself that were missed. After looking at the problem areas he assured me they were absorbing sutures and would go away. It has been about a month now and I was in to see my Dr yesterday who was kind enough to lance yet two more bloody blisters from my donor scar to remove two more suture loops confirming with me they were in fact non-absorbing sutures. He said he witnesses this a lot when patients attempt to remove their own sutures.

 

It was very awkward listening to Dr. Reese's explanation in ethics of why he will not prescribe finasteride for alopecia in other marketed\generic forms rather than the costly Propecia telling me they are not the same thing... Other than the candy coating, they without doubt both contain the same active ingredient which is in fact finasteride. Any other Dr or even a sales rep from Merck will tell you the same thing.

 

I would expect a surgeon who tells me he has ethical issues prescribing a generic form of finasteride over Propecia would have the integrity to tell me sorry; it looks as though my assistant missed a few sutures during the removal. Let me get those out??¦

[Maxxy]

I received dissolvable sutures for the length of the donor along with standard sutures as tension stitches. The tension sutures were removed 5 days later and of course the dissolvable sutures remained. For a long time afterwords (some months), I could feel lumps where the dissolvable sutures were tied, I was also concerned about these but they did go after a while.

 

Is it possible they were dissolvable sutures but due to the issues you had with blisters forming the doctor thought it best to remove them?

[ukjoe]

No. They were the black heavy threaded sutures. The worst was like a never ending bloody scab that would not go away. Dr Reese looked at it as did his staff. His staff said she saw nothing. Reese with his magnifying glasses said he could see some of the "absorbable" suture poking through. My Dr pulled out a knotted loop he guess the assistant just pulled deeper into the wound when she was removing the rest. I feel like there are a couple of more. I've had a few surgeries and I am all too familiar with disolvable sutures. These were not. It was just frustrating having Reese tell me otherwise to cover his own ass or whatever the reason. He's far from incompetant.

 

This is my first surgery having graphs this small. It's been about a month now and a bunch are already growing in. It's like some of the previous hair never shocked out, it just continued growing. I've had about 6-7 smaller surgeries over the past 15 years with David Kelsey and this is pretty different. 1600+ is a hell of a lot more itchy!

[Sparky]

Finasteride and Propecia are the same, hes just trying to rip you off by the sound of it.

[Daniel Leach]

I have had the pleasure of working with Dr. Reese now for nearly a decade and have heard him explain thousands of times why he will not write a prescription for finasteride. As the creater of this thread points out finasteride and Propecia are the same thing. While this is true, the issue here is that propecia is prescribed for the treatment of hair loss which is generally considered cosmetic and not covered by insurance plans. Additionally, Propecia is still under patent protection. For years finasteride has been prescribed in the 5mg dosage for the treatment of the prostate(aka Proscar). Proscar is typically covered by insurance since treating the prostate is medically necessary. Dr. Reese does not perform a prostate exam and does not treat these types of problems in his clinic. He performs hair transplant surgery. I want be absolutely clear about the reasons Dr. Reese will not prescribe finasteride. The risk is too great that patients will end up using their insurance benefits to purchase finasteride or Proscar thus leaving Dr. Reese vulnerable to insurance fraud. I which watch this thread and if I can provide any additional information, just ask.

 

Thanks,

 

Dan Leach

[Sparky]

So more to do with protecting himself against insurance fraud than ethics.

 

Thats fine and understandable, but nothing to do with ethics, lets just get that straight.

 

We dont have infinate pockets, the sooner HT docs understand that the better.

[Daniel Leach]

I want to make sure that I understand your logic. Merck is a giant corporation that makes millions, maybe even billions of dollars each year. So what you are saying is that it is ok and ethical for physicians to write prescriptions that infringe upon Mercks patent protection and may joepardize that physicians livelyhood if patients fraudulently use their insurance benefits. It's ok because Merck makes enough money? Right? Let's turn that around however, and say Dan Leach (who is not rich by any means) has a patent on a product and a big company arbitrarily decides to use my patented product without paying me for it. We would all be up in arms. Right? It has as much to do with ethics as it does with protecting himself. I don't like the cost of Propecia either....but your argument is with Merck not Dr. Reese.

[Sparky]

I still dont think ethics come into it.

[Sparky]

Ethics would be not prescribing it because it causes side effects.

[Sparky]

Is it illegal for Dr Reese to prescribe the non rip off version of Propecia? if so thats a different matter and still nothing to do with ethics.

[Daniel Leach]

Hello to all, this is Dr. Reese. I was asked to respond to a comment that was made from one of my patients concerning the use of Proscar as opposed to Propecia as an aid to stop ongoing hair loss. Yes, both of these trade names, (Proscar and Propecia) represent the generic medication finasteride. Proscar, (finasteride 5mg) is indicated for the treatment of bladder outlet obstruction, commonly known as BPH. Proscar is covered by insurance companies for the above mentioned medical indication. Proscar does not have an accepted indication for the treatment of androgenetic hair loss. Nonetheless some patients attempt to obtain a prescription for Proscar, (and therefore decrease the cost of the medication) so they can quarter the tablets and use it in a dose that is close to the dose of Propecia, at a cost that is lower than purchasing Propecia directly. Propecia, (finasteride 1mg) is indicated for the treatment of androgenetic hair loss. The cost of Propecia is rarely covered by an insurance company. In my geographic area Propecia will cost $65. or more to use for a month of therapy. I do inform my prospective patients at the time of their initial consultation that stopping ongoing hair loss is an important issue in the patient ultimately obtaining their "density and coverage" goals. I inform them that since Propecia is not yet available as a generic, (it will be in mid to late 2013) that if they choose to use the medication, that they will have to pay more for a few years until the generic is available at which point the cost will come down. I inform them that as a hair transplant surgeon I will not be performing a prostate examination on them, and as such do not have a medical indication to prescribe Proscar. In my opinion, to do would raise ethical concerns that I am not willing to expose myself to. If a prospective patient has a medical indication to utilize Proscar, that is a condition that is diagnosed and treated by their primary physician and/or a urologist, but not a hair transplant surgeon. While I empathize with this group of patients, I do not create the rules that I am governed by. I simply follow them. And as such I have not been exposed to questions about ethical conduct in the past. What this patient did not expose on this site is that he met with his primary care physician and requested that he provide him with a prescription for Proscar but was turned down by this physician because there was not a medically necessary indication for the use of Proscar in his case. What this patient did not state in his e-mail is that he informed me that if I wrote him a prescription for Proscar he would not have it filled through his insurance company, but assured me that he would pay for the prescription himself. Obviously, once the prescription is provided to the patient, it is out of my control, and whether or not he did as he told me would be unknown to me, unless I was notified by the State Medical Board that I was providing patients with unauthorized prescriptions. Again, this is not a practice that I choose to participate in. Not in the past, not now, not in the future. Once finasteride is available as a generic, I will be happy to provide it to my patients in this form. Until then, I will not. It is also unfortunate that there are some individuals who choose to anonymously disparage quality physicians because they do not "get what they want", irrespective of the guidelines that physicians must practice under. I enjoy a very good reputation for my work. My staff and I have worked very hard to provide our patients with an excellent experience when in our care, as well as give them an excellent result with their procedure. For the past ten years I have very successfully competed with some of the most outstanding hair restoration surgeons in the world who are located in my own geographic area. If my work was not as least as good, I would not have survived let alone thrived in this environment. My work stands on it's own merits. My ethics stand on their own merits. As such I have been rewarded by my contemporaries by being asked to become a member of the Board of Directors for the American Board of Hair Restoration Surgery. I have also been appointed Chair of the Written Examination for the ABHRS. I have been accepted as a Member of the International Alliance of Hair Restoration Surgery, (several of my video posts are located there for review). I am Certified in General Surgery, as well as Hair Restoration Surgery. I am a member of the Department of Surgery of two hospitals in the Twin Cities. My credentials are second to none. Certainly I am not perfect, but I do work hard for my patients, and they benefit from my efforts on their behalf. In my opinion, if an issue/concern arises it is best dealt with directly, man to man, face to face, as opposed to anonymously on a web site. Thank you for the opportunity to respond. Dr. Robert J. Reese.

[Anouar]

I got my generic proscar from my doc. Go to ur regular doc

[Bill - Seemiller]

UKJoe (and everyone),

 

Dr. Reese is right. Though some hair transplant surgeons will prescribe Proscar under certain conditions, there is the legal matter of insurance fraud that physicians have to worry about. Ultimately, even though Propecia and Proscar contain the same active ingredient finasteride, they are actually manufactured and sold for two different purposes. If a physician prescribes a medication for a non-intended use (even if the active ingredient is the same) and the insurance company does a check-up, the physician could get in trouble.

 

Dr. Reese isn't saying that Proscar and Propecia don't contain the same active ingredient to stop hair loss - only that because the medications are intended for different uses, he can't without all liability prescribe Proscar to his patients. Any evidence of insurance fraud would fall back on the doctor who prescribed medication for a non-intended purpose.

 

On a personal and related note, since "androgenetic alopecia" wasn't listed as a condition treated by Proscar, my general practioner denied me a prescription for it when I asked.

[Sparky]

Hurt my eyes reading that wall of text, paragraphs make things so much easier.

 

Like I said in my last post, if its illegal for Dr Reese to prescribe Proscar, then I agree, but it would of been better to say that in the first place than make it all about ethics.

[ukjoe]

I'm not sure what you think Dr Reese is right about in my original post. There has been a lot of confusion in many of the responses in respect to my original post but I know these boards go off in many tangents. A few of you are citing insurance fraud which is not an ethical dilemma but a legal issue. My Dr prescribes finastride for me. It isn't billed as something else other than for the DX of alopecia. It's not covered by my insurance and we are not trying to fool the insurance company. I pay out of pocket 100% so there are no legal concerns. I explained this to Dr Reese but it is what it is I guess.

 

Also there is a lot of mention that there is no generic drug for Propecia in this post and from Dr Reese. The FDA clearly labels finastride as a generic drug for Propecia. I'm not sure what other definition of "generic" one would reference for a drug other than that of the FDA.

 

As for Dr Reese, I have no argument with him at all. Ethics are a grey area. Some border on legalities and some do not and these are choices each and everyone of us must make and I respect his decision. I completely disagree with it and by his reasoning; the FDA does as well so it just doesn't make sense to me.

 

This kind of reasoning could make one wonder who does and does not have stock options in Merck...

[Bill - Seemiller]

UKJoe,

 

few of you are citing insurance fraud which is not an ethical dilemma but a legal issue

 

So you don't think it's unethical to do something illegal?

 

Also there is a lot of mention that there is no generic drug for Propecia in this post and from Dr Reese. The FDA clearly labels finastride as a generic drug for Propecia. I'm not sure what other definition of "generic" one would reference for a drug other than that of the FDA.

 

He's referring to a generic version of Propecia that contains 1mg of finasteride. Generic Proscar exists, but not generic Propecia.

 

Bill

[ukjoe]

No Bill, it's not always unethical to do something illegal. Would you break the speed limit to get someone in an emergency to the hospital? Ethics are not black and white. And defrauding insurance has nothing to do with my original post. That has all been assumed by others posting...

 

Who decides if there is a generic for Propecia if not the FDA? Are you saying the FDA is wrong? Check out their website.

[Maxxy]

Originally posted by ukjoe:

No Bill, it's not always unethical to do something illegal. Would you break the speed limit to get someone in an emergency to the hospital? Ethics are not black and white. And defrauding insurance has nothing to do with my original post. That has all been assumed by others posting...

 

Who decides if there is a generic for Propecia if not the FDA? Are you saying the FDA is wrong? Check out their website.

 

That is hardly the same thing. You can't compare ethics in an emergency to the ones we are discussing.

 

There are my many Propecia generics available however Merck holds the patent in many countries. As Dr. Reese states 2013 for a generic to become available, I'm guessing this is when it goes off patent in the States. Even when the patent runs out, generics won't instantly flood the market.

 

Personally, I don't see what the problem is. There are so many other options available to us. If you were not going to put it through your insurance and you're not happy with the doctors decision regarding the medication buy it elsewhere.

 

On a related note, I believe there are generics available in the UK but these are still priced ridiculously high.

[Sparky]

I pay ??100 for just over a years supply, seems cheap to me.

 

P.S we dont have to get health insurance over here so it doesnt even come into it.

[Sparky]

This is Spex's website and it has the name of a GP that prescribes it on there. (tell him that you got his number off of Spex's website)

 

 

http://www.hairlosshelp.com/websites/spex/

[Maxxy]

Are you actually buying Proscar, a 5mg generic or is it 1mg Finasteride?

 

If it's Proscar or a generic version, that's something totally different. Spex's doctor-contact is prescribing Proscar off-licence and therefor taking more medico-legal responsibility. Any doctor can do this if they wish too, however, that is exactly the main reason why Dr. Reese won't, because it would be off-licence in the States as it is here in the UK.

 

If you are buying 1mg Finasteride, could you tell me which brand please?

 

P.S. I suspect the doctor is also supplying the medication, if so - that has no bearing on a cost-effective generic Propecia being available in the UK on prescription.

[Sparky]

Ah I am buying the 5mg, whats the point in buying 1mg? so you dont have to spend 5 mins cutting it up?

[Maxxy]

Lol. No, I also buy 5mg but that isn't what was being discussed in the thread.

[Sparky]

ok

[Dr. Paul Shapiro]

When I read this tread I think that there may be confusion as to what constitutes insurance fraud and what constitutes prescribing a medication off label.

Prior to becoming a hair transplant surgeon I had vast experience in medical administration and had to be very conscious that my employees never engaged in insurance fraud. I worked for Glens Falls Hospital as a Medical Director of their Rural Health Clinics, and then as Associate Medical Director of the New York University Student Health Center, and also as a Medical Director of a Home Health Agency.

When a drug gets approved by the FDA, the drug company needs to study the drug and prove that it is efficacious for the treatment proposed. Then it gets approved by the FDA for only the treatments that the drug company proved it was effective for. Prescribing that drug for any other reason is considered prescribing off label, but not fraud. A good example of this practice is a drug called Neurontin (Gabapentin). It is a drug that has been approved by the FDA to treat post herpetic neuropathy (the pain one gets after having shingles). But it is common in pain management to prescribe it for patients with chronic pain such as sciatic back pain. That is prescribing the drug off label, but it is not illegal.

If I prescribe Finasteride 5mg at a does of ?? pill daily for hair loss and document in my note that I am prescribing it for hair loss with the instructions to split the pill into fourths, I am not doing anything fraudulent or illegal. I am writing an off label prescription. When the insurance company sees the Finasteride is prescribed that way it can then chose whether or not to cover it. If I prescribed it at the dose for benign prostatic hypertrophy which is 5 mg a day and some how indicate that I am prescribing it for the prostate when the patient does not have benign prostatic hypertrophy, then that can be considered insurance fraud. Also it would send a message on the patient's medical record that they have a prostate problem which isn't correct and could cause problems down the road since it seems like they have a pre-existing condition.

Logically it makes sense that splitting the 5mg Finasteride into fourths would be as effective as taking the drug as Propecia. But since this has not actually been studied clinically I usually advise patients who are taking the medication for the first time to take it as Propecia at least for the first year. Then if it does not work there is no question as to whether the cutting of the pill in any way affected the outcome. The FDA just recently put out a good article of why tablet splitting can be risky: http://www.fda.gov/ForConsumer...pdates/ucm171492.htm

Also, if there is a female in the house hold who is trying to get pregnant; one has to be especially careful that she is not exposed to the powder from cutting the pill.

Merk has a good rebate plan for patients who are taking Propecia for the first time. This rebate program helps reduce the cost of the Propecia for the first year and I find it is a good incentive for first time users to use the brand name Propecia.

I do agree with Dr. Reese that if I prescribed the Finasteride at the 5mg dose and did not document that I am instructing the patient to cut the pill into fourths and that the prescription is for the treatment of hair loss that could be considered insurance fraud. But with the correct documentation and writing on the prescription clearly that I am instructing the patient to cut the pill into fourths and take one fourth pill a day I do not believe I am doing anything illegal or fraudulent.

I hope this is helpful

Dr. Paul Shapiro