Last Word

October 21, 2005

PBM roadblocks: Designed to frustrate

I'm not against pharmacy benefit managers. At their best, PBMs encourage us to choose cost-effective treatments, avoid dangerous ones, and alert us to patients who might otherwise be abusing the potentially addictive prescriptions we prescribe. My sympathy goes even further, in fact: As a member of an insurance company's pharmacy and therapeutics committee, I sometimes advocate, as PBMs do, that certain expensive and less-effective drugs be pre-authorized.

But my willingness to understand PBMs' role in today's healthcare marketplace has its limits, especially when I suspect that the pressure on them to turn a bigger profit has trumped their other mission, to provide cost-effective care.

In 2004, for example, Medco Health Systems, the nation's largest PBM, paid $29.3 million to settle federal charges that it had inflated drug prices-and improperly adjusted patients' prescriptions-to boost profits.

But when my patient showed up at her local pharmacy to get her script filled, the pharmacist told her that he couldn't provide the medication until I obtained prior authorization from her insurance company.

Frankly, I was puzzled when he called to inform me of the problem. After all, azithromycin was not only one of the most-often prescribed antibiotics for pneumonia; it wasn't especially expensive. I held my ground, refusing to substitute another.

"What's the company's preauthorization line?" I asked him. He couldn't tell me, because, incredibly, the company listed only its fax number on his screen. But I did succeed in getting him to ask my patient to look on her insurance card for her company's member-relations department. After a lengthy hold, that department gave me the number for the company's PBM.

The office was closed, but there was an emergency services number I could call. After another lengthy delay, a senior pharmacy tech came on the line, explaining that, sorry, he wasn't permitted to approve the prescription based solely on my call. No, the pharmacist himself had to call and request an emergency prior authorization. Stunned and furious, I let him know what I thought of the runaround I'd been getting.

I called back the pharmacist, who was overwhelmed by customers and balked at calling the PBM. Instead, he offered to dispense a single day's medication, putting off the call for the rest until tomorrow.

By this point, I'd had it. My patient had already been waiting around for a half hour-and she was too sick to return tomorrow for the whole prescription. Instead, I invited her to return to my office, where I had sufficient samples to complete her entire course of therapy. If the roadblocks my patient's health plan and its PBM had been erected to discourage doctors like me, they'd succeeded. The companies had won.

Some PBMs like to claim that healthier patients and a healthier bottom line aren't incompatible-in fact, one goes hand in hand with the other.

Given all I know, that's a big pill to swallow.