The Way I See It: Helping patients shouldn't hurt me!

June 6, 2008

The author's extra effort to get low-cost drugs for her patients works to her detriment under P4P.

Wal-Mart's $4 generic drugs, as well as free antibiotics offered by a local pharmacy, help a lot of my patients. Whenever possible, I prescribe medicine available for $4 for patients who have a $10 copay for generics; for those on multiple meds, that $6 difference can really add up. And I send patients who have trouble paying for antibiotics to the pharmacy where they're free.

But there are times when I wonder whether I'm hurting myself by helping my patients. Let me explain.

I have a patient named Benny, who's a school custodian. He doesn't make a lot of money, but until recently he had great health insurance. Last year, with layoffs threatened, the union agreed to switch to a local HMO.

In the HMO, Benny's copays rose to $10 for generics and $40 for brand-name drugs, with no coverage for nonformulary drugs. Of the 11 prescriptions he had when his insurance changed, only two were still available to him, and his copays for them had doubled.

Benny came in to get the rest of his medications switched. "Give me something I can afford, Dr. Roy, or I'll just have to stop taking them," he told me. "I can't afford to pay $300 a month for drugs."

So I spent two hours doing my best to switch everything to affordable products, working with the formulary and Wal-Mart lists at my side. We also took advantage of the HMO's mail-in program, and I gave him some samples. Benny left with his fingers crossed and a lab order to check everything in 12 weeks.

He came in yesterday to go over his results. His HgbA1c is up to 8.2, his LDL-C is 130, and his blood pressure and microalbumin are high. With his prescriptions fragmented among mail order, the local retailer, and drug samples, it's only a matter of time before he'll accidentally get double doses or the wrong drug. To top it off, his new plan is big on pay for performance. So not only are his clinical indicators rotten, but all the work I'm doing to try to fix them will count against me.

The local P4P programs grade and pay doctors partly based on our percentage of generic prescribing. But when patients take advantage of great deals on generics offered by giant retailers, the insurance companies are left out of the loop. Consequently, they're clueless as to the actual number of generic scripts I write.

I got a letter from one insurance company this week informing me that I wrote a larger percentage of second-tier antibiotics than other FPs did. In fact, all the generic antibiotic prescriptions I write fall under the radar. So my percentage of generic prescriptions, always very high, has dropped, according to the health plan, and my second-level prescribing has increased. That means I'm going to get dinged when it comes time to dole out P4P rewards.

How can doctors win when we're harmed by our efforts to help our patients?