Prescription for disaster?

Patients in the St. Louis Veterans Administration Hospital are dying because of a bureaucratic managed care program, according to a former VA doctor.

Lawrence A. Hagler, a Korean War veteran was a month from death in October 1995 when Dr. David Moskowitz first began to treat him with high doses of a medication not normally used for end-stage emphysema.

“Mr. Hagler did unexpectedly and extremely well, to the point where I think he represents a new and much more effective treatment for emphysema than now exists,” Dr. Moskowitz told WorldNetDaily in an exclusive phone interview.

Instead of receiving praise for discovering a successful treatment, Moskowitz says he was subjected to harassment and the loss of his career as a VA physician.

Moskowitz, a nephrologist and general internist at the St. Louis VA Hospital from 1987 to 1998, was responsible for about 1,000 patients. Approximately 200 of those patients were suffering from kidney problems that normally lead to kidney failure, dialysis, and eventually death. He was also treating hundreds of patients with high blood pressure who would most likely progress in their illness.

Dr. Moskowitz had been conducting successful research, paid for by the VA, which led to the discovery that drugs known as ACE inhibitors would delay or prevent progress of kidney problems, control high blood pressure, and prevent the progress of end-stage emphysema and reduce the symptoms.

When Hagler became a patient, Dr. Moskowitz had already discovered the effects of higher than normal doses of the ACE inhibitor drugs on his severely ill patients. He said Hagler was only weeks from death when he met him. If he was going to help this gravely ill man he had to do something radical, and he had to do it quickly.

“I frankly only used the ACE inhibitor for his end-stage emphysema because my lab had found an association for the genes for the ACE enzyme with emphysema. If I didn’t do anything he’d die and if I did something there was an outside chance that maybe he’d do well, and in fact he did extraordinarily well,” explained Dr. Moskowitz.

He immediately began treating Hagler with higher than normal doses of the drug ramipril. The VA pharmacy allowed Dr. Moskowitz to prescribe the non-formulary prescription after he provided some necessary paperwork. Hagler’s symptoms improved and all was well until July 1997 when Hagler and most of the other patients receiving the new treatments were denied further medication by the VA.

To comply with managed care provisions enacted by Congress, the St. Louis VA would no longer permit physicians to prescribe non-formulary medications for patients, nor would they permit doses higher than established by the FDA. Hagler was placed on a lower dose of a different drug and immediately his symptoms returned. Without fast action he would die very soon.

Hagler has been kept alive only because Dr. Moskowitz obtained complimentary medication from the maker of ramipril, first from Hoechst Marion Roussel and now from Monarch Pharmaceuticals. Hagler receives the medication each month when his doctor makes a regular monthly house call.

Prescription drug assistance programs for those without means to pay for the drugs themselves are available from many companies. Many drugs can be obtained no cost or low cost for those who qualify.

Dr. Moskowitz is no longer an employee with the St. Louis VA Hospital. He claims his patients were removed from his care and placed on insufficient medication dosages to save money and comply with bureaucratic requirements instead of doing what was right and best for their health. He claims he was harassed to the point where he was forced to resign.

Because of a settlement he made with the VA over his employment, he was unable to provide the details surrounding the end of his promising career. The St. Louis VA Hospital would not comment because it was a “personnel matter,” according to John Patrick.

Paul Sherbo, national director of VA public affairs, confirmed that VA policy does not permit him to comment on issues regarding personnel. “It’s a privacy matter,” he said.

“The VA was basically taking away a drug that was keeping a patient of mine alive,” said Dr. Moskowitz. “I was absolutely convinced that Mr. Hagler would not be alive past October or November of ’95 if it hadn’t been for this drug.

“All of a sudden, just to comply with the managed care imperatives that were coming down from Washington, it seemed like the people in charge had suddenly been given the power to take medicines away from individual patients and their physicians. They were exercising their power without any regard to bad consequences that would befall the patient.”

Hagler was not the only patient impacted by the change in policy.

Dr. Moskowitz was giving his renal patients high doses of quinapril, which is normally given for high blood pressure. He was also giving the drug to his patients with high blood pressure, at higher than the FDA recommended dosages.

“Doctors use drugs higher than FDA doses all the time,” explained Dr. Moskowitz of the practice. “They titrate the drug to get to the effect that they want.” Many of his patients had received the drug for more than 18 months and were responding extremely well.

He said it was while doing research for the VA in 1994 that he discovered that ACE inhibitors could be useful in the treatment of more diseases than what was currently believed. He soon found himself with 800 hypertension patients, 200 kidney (renal) patients, and Hagler with emphysema and hypertension.

He helped them all with the treatment. In fact, he claims the renal patients reduced the progression of their disease by four to one. If they would have gone on dialysis in a year it was delayed for four years. People with vascular disease were able to reduce their need for surgery, or at least delay the need for a year or more.

All the 1,000 patients were eventually removed from his care and forced to take much lower dosages of their medication. The result was a return of their symptoms and renewed progression of their particular disease.

Hagler would face death in a matter of weeks if his medication was stopped, so Dr. Moskowitz has continued to see him on his own and to obtain the necessary medication to keep him alive through a pharmacy program for those who are indigent.

The majority of VA patients throughout the country are described by Dr. Moskowitz as the oldest, sickest, and poorest population — making managed care a bad choice for their care. He said the approximately 3 million VA patients in the U.S. are not getting the treatment they need because of the managed care system put in place by the Clinton administration with the help of Congress.

“The delays are built in. You have to go through the primary care physician to send a patient to a specialist,” explained Dr. Moskowitz of the problem he sees.

“It takes several months to get in to your VA primary care doctor,” he said. “So if somebody in cardiology noticed that a patient also had a significant component of emphysema and wanted to send the guy to a pulmonary specialist, he would first have to get the patient back to see his primary care doctor which would take two or three months. Then the primary care doctor would have to put in another consultation with the pulmonary guy. The whole thing would take two or three more months. So instead of seeing him right away it would take six months to get the patient taken care of.

“With these guys, the difference of six months can make the difference of them being alive or not. When I was there, people were already starting to drop dead in the parking lots on their way in to their regular visits. To delay any more in the delivery of care for these guys I think boarders on criminal,” he proclaimed.

Other doctors are not complaining or pushing the issues Dr. Moskowitz is so concerned about because they have been intimidated, he claims.

“The simple truth is that if you have to feed your family you tend to put troublesome things like the Hippocratic oath aside,” he said. “So what bothers me about this whole episode with Mr. Hagler is not only the profound silence that all the national media met this case with, and not just the profound silence that Congress met the case with, but the implications are just so clear. It’s just such a debasement of the practice, the profession of being a physician. It’s really an evil thing that’s going on,” he concluded.

“It makes any physician in the system in the same category the German physicians were in during the ’20s and ’30s when Nazis came to power and decided that they were just going to let patients die or even kill them because they were costing the state too much money.

“What I found out is that if you’re a federal agency and you have the White House behind you, and congress behind you, and if it’s your mission to kill people there’s not a damn thing that will stop you. In a very real sense, our country is very much the same as Germany was in the early ’30s.

“It was very upsetting to me to see that the checks and balances that are supposed to exist don’t exist at all,” Dr. Moskowitz said in frustration.

He believes a new agency of government should be created to protect citizens from government abuse. He suggests the formation of an ombudsman’s office to fight for citizens who would otherwise have nowhere to turn.

“There are 250 million of us paying taxes to create this monster of the federal government to pick on any one of us at any time they want. This is not what the founding fathers had in mind. I really think the federal government is way out of control,” said Dr. Moskowitz.