Physicians often favor nonformulary drugs unnecessarily--and at great expense to their patients.
Physicians often favor nonformulary drugs unnecessarilyand at great expense to their patients.
Six months ago, after 22 years of primary care practice, I became a medical director for a not-for-profit health plan's HMO. With the end of the year approaching, I've noticed that many of our senior members are exceeding their prescription plan limits. I'm sure you've heard their financial woes and fears of being forced to stop taking their medications.
Although you can't do anything to change their prescription limits, often you can change their medications. Many patients are on expensive brand-name, nonformulary products for hypertension, cholesterol, or diabetes, even when generic or formulary medications have been shown to do just as well. Maybe their pharmacy benefits would have lasted the year if their physicians had been more judicious in their prescribing.
You're probably thinking that any savings achieved by favoring generic or formulary alternatives would boost health plan profits rather than patients' benefits. But in a not-for-profit plan, at least, that may not be the case. The one I work for does try to pass savings onto its members.
Even the prescription benefit that Congress just passed for seniors won't go far if the current prescribing trend continues. And as more employers shift costs to employees and more people lose health insurance, the cost of prescriptions will become a bigger issue for non-Medicare patients, too. Most insurers already charge higher copayments for nonformulary brand names.
Naturally, we want to do what others are doing, to see quick results, to use the most up-to-date treatments, and to avoid side effects. The newer medications neatly fit that bill, but it's important to remember that the older drugs still work. Patients who could take them should at least be informed about them and given a choice. Rather than paying more for an angiotensin II receptor blocker, for example, a patient of modest means might be willing to try a generic ACE inhibitor and ride out the cough that might result.
For some patients, having a choice could mean the difference between compliance and noncompliance. Studies have shown that some patients with diseases like hypertension don't improve because they don't take the medications prescribed or don't take them in the manner prescribed. Sometimes cost is a factor. So when patients don't respond to treatment, we might ask, "Are the costs of your medications preventing you from taking them or taking them properly?" If the answer is Yes, maybe switching to a less-expensive alternative would help. When patients are on multiple medications, we may even want to rank the drugs in order of importance. That way if they find they can't afford all the medications, they're less apt to skip the most critical ones.
Whenever lifestyle changes might eliminate the need for certain medications or help make less-expensive ones viable, we also should impress on patients that making the changes could save them a substantial sum. Then they might be more inclined to try, especially if they're facing coverage limits or higher copayments for medications. For instance, I found that by consistently following all the recommended lifestyle changes for reflux esophagitiseating small meals, avoiding fatty foods and alcohol, not eating before bedtime, and elevating the head of the bedI eliminated my daily proton pump inhibitor. With an insurance copayment of $20 a month, that saves me $240 a year. Similarly, some patients who are willing to exercise may be able to lower their blood pressure and control their diabetes enough to go off medication.
It's equally important to make sure that any medication a patient does take works well enough to justify the cost. When we identify depression or cognitive decline in a patient, we typically prescribe an antidepressant or an acetylcholinesterase inhibitor. Sometimes, the patient makes a remarkable turnaround and the drug's benefit is clear. But often we continue prescribing medications that seem to help only a little. Why not ask the patient or the family if the benefit is worth the cost? We don't have to treat something just because we can.
Similarly, giving medication to reduce cholesterol is clearly sensible when someone has had a heart attack. But with patients who haven't, we should discuss how much risk reduction they can expect from medication and how much they'd pay for it. Then they can decide whether they value the intervention.
Taking the time to evaluate all the options can help avert some other problems as well. We all know the frustration of being called after hours to change a patient's prescription, for example, but often we can avoid this. Many plans already have their formularies online or on Palm applications, or they soon will. Before a patient leaves the office, we can have a staffer make sure the medications we want to prescribe are in the plan's formulary. Another solution is to write multiple choices for the pharmacist, such as "Zoloft 50 mg; if not covered, then Paxil 20 mg; if not covered, then Prozac 20 mg."
We should think twice before handing out samples, too, if patients will have to change to formulary medications later. It may be better to give them prescriptions for formulary choices from the start, especially if they'll be on the medications for a long time.
And when considering what medications to prescribe, we need to look beyond pharmaceutical company claims. For many medications, the PDR lists the studies used to approve the drug. I've been surprised to find that some drugs were only effective when the patients in the studies were treated in a way that isn't practical in everyday practicefor instance, within 24 hours of developing symptoms. In such cases it's unlikely that our patients would benefit enough to justify the cost. Sometimes, multiple studies were conducted and some showed no benefit. In other cases, even though the medication was effective, the benefit wasn't convincing enough to warrant the expense.
Weighing costs and benefits also makes sense when a patient who transfers to us from another doctor is taking multiple medications for which the rationale is unclear. In that case we must consider whether some of them can be dropped. Unfortunately, the medical records from the doctors who issued the drugs often aren't available. In such cases I've found that it's best to take things slowly and reduce the dosages in small steps over several visits. I tell my patients what to expect and check them frequently for adverse reactions.
Pharmaceutical costs have increased more than any other aspect of healthcare spending over the last several years. With some drugs costing thousands of dollars annually, we need to do all we can to ease the burden on our patients. It's unfortunate that they're the ones caught in the financial middle as we battle over formulary medications.
Gil Solomon. Forget Canada: You can help patients cut drug costs.
Dec. 19, 2003;80.