Insurance Company Causes Negative Patient Outcome

Many patients get medication management suggestions from their insurance companies addressed to their primary physician.  A patient who had diabetes and CHF was not on an ACE Inhibitor or an ARB which are commonly recommended as standard of care for hypertension and these coexisting conditions.  In following this patient, there were records that an ACE inhibitor had been tried in the past and had been discontinued due to hyperkalemia (elevated potassium).  The patient had recently switched to a new physician who received the letter and proceeded to put this patient on Lisinopril.  Sure enough, after checking some lab work, the lisinopril was causing hyperkalemia again and was discontinued.  A few questions I’d like to get some interprofessional thoughts on: 1. Should the new provider have caught this and are they totally responsible?  2. Should the adverse effect have been noted in the allergy/intolerance list – Many adverse effects in my experience are not added to this list? 3.  Did the insurance company letter set the patient/prescriber up for this negative outcome and should insurances send out these letters?


  1. Saba Syed

    The reason why these letters are sent out by insurance companies is because Medicare plans get quality ratings from CMS. One of these measures is what percentage of diabetic patients are on an ACE-I/ARB. I don’t foresee these letters stopping anytime soon and the underlying premise is to improve overall patient care. I wouldn’t say the insurance caused the negative outcome. The prescriber still had the responsibility for due diligence when initiating new drug therapy.

    • chri1599

      Thanks for the response!

  2. AudibleRx

    Thanks for this discussion. I agree that the prescriber has a liability to check the patients previous records; however, had the patient been using the regular pharmacy and had the pharmacist at this pharmacy reviewed the patients profile perhaps the situation could have been averted at the counseling counter. Not only does the pharmacist have access to the patients previous medication profile, the pharmacist also has due diligence to consult the patient about their new medication. During this discussion it is conceivable that the pharmacist and the patient may have come to the conclusion that they have tried this med in the past with an adverse outcome; in which case the pharmacist would then follow up with a phone call to the physician. I am just saying, pharmacists have struggled a long time to gain a clinical foot hold, we should also step up and take some of the responsibility for a situation gone wrong if we are planning on being a part of the team.

    • Stacey

      I’m sorry, but I disagree. Sure, in an ideal situation the pharmacy would have access to all records and be all knowing about what the patient has tried in the past, but many times this is not the case. Even if the patient had received the ACEI/ARB at that pharmacy in previous years, how far back must one review the patient’s profile? (and how does one know that it was stopped due to an adverse affect?) I don’t know how your pharmacy is, but many times the pharmacist is coming to the counsel window blind. They may not have been the same pharmacist that checked the prescription, it may be days later that a patient is picking up. If it is not noted in the “allergies.” it is unlikely that the pharmacy software has a section of trialed and failed meds.

      • Steve Leuck

        Stacey: You bring up an excellent point. You raise many good reasons why it would be highly improbable for a pharmacist to pick up on this issue with the patient at the pharmacy counter. Pharmacists share a corresponding liability with the prescriber regarding the appropriateness of medication therapy. My point here is that it is not solely the fault of the physician, pharmacy, insurance company or patient; but rather all parties played a part in this error. When I see something like this I like to think of my own practice and consider how I might change or improve the flow to so I may change the probability of preventing something like this from happening in the future.

  3. Janet

    For safety’s safe, these intolerances should be listed in the allergy section of the patient’s profile. I’m not clear on why this isn’t common practice for all prescribers. At my practice, I list intolerances (eg. ACE-I:
    hyperkalemia) and you can always decide to use the medication, if needed, but you know what to expect and monitor.


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Written By Eric Christianson

May 28, 2014

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