Lowering Prescription Drug Costs
Mar 27th, 2008 | By Jose DeJesus MD | Category: Physician NewsSenator Kohl of Wisconsin and Senator Durbin of Illinois plan to introduce legislation to authorize federal grants for a program to prepare educational materials and to “train health professionals to conduct visits to prescribing physicians”, according to a NY Times 3/20/08 editorial, endorsing this program as a counterweight to advertising programs by drug companies for their latest (and more expensive) drugs. The justification for this program is that it is espected to pay for itself in savings to federally-funded programs, such as Medicare Part D and Medicare Advantage. The full editorial is here:
NY Times Op-Ed.
The obvious initial beneficiaries of this programs are those who will receive the Federal grants, but before heading down this road, perhaps the good senators should consider a few points:
- Medicare Part D and Medicare Advantage Already Use Restricted Formularies
If a patient walks in and asks for a prescription for the latest drug they saw on TV, it probably won’t be covered by Medicare unless the Pharmacy Benefit Manager has determined that there is compelling evidence for adding that drug to their formulary. If there are two other cost-effective drugs in the same theraputic class, there is a good chance that the new drug won’t make it onto the forumulary. There are special rules covering true medical necessity cases but, as a general rule, Medicare is not paying for expensive me-too drugs.
- Medicaid Pharmacy Benefits for Senior Citizens are Integrated with Medicare
When Medicare Part D was implemented, it was integrated with Medicaid and therefore many of the formulary restrictions mentioned above also affect Medicaid patients. - Doctors are Not Stupid and they Do Read
- Physicians spend a considerable amount of time in continuing education, and try to keep up with the various formularies published by the insurance programs that cover their patients. They know that if a drug is not on the formulary and is not covered, there is a good chance that their patients will get sticker shock at the pharmacy, and will either not follow their prescribed treatment plan or will place an angry phone call to the doctor’s office that will require the doctor to come up with a less-expensive or covered drug.
- On the other hand, sometimes a patient requires a specific drug because others have been tried and found to be ineffective or for some other legitimate medical necessity. CMS has a directory of all the Medicare drug plans with what are SUPPOSED to be direct links to pages that detail each plan’s formulary here: Medicare Drug Formularies
Some Actually Useful Suggestions
- CMS can do a much better job of providing direct links to the formularies of each plan. Not every plan provides a direct link to its formulary and the physician or patient is forced to navigate through multiple pages and fine-print menus of links to actually arrive at the actual formulary for a plan. Try finding the full formulary for the AARP plans – you have to go through half a dozen steps to do so, including looking up a specific drug and dosage before you get a direct link to their formulary as part of the response. This is a no-brainer improvement that does not require any new legislation or rule making.
- If the Federal government wants to take an active role in making formulary information more readily available to physicians, it can start by making all Federal pharmacy plan formularies available through a central location, accessible by plan name and BIN number (the standardized plan number printed on all pharmacy benefit cards).
- The next step, which would require some cooperation, would be to coordinate with state insurance regulators and to reach out to private insurance companies and pharmacy benefit plan managers, and add links to the formularies of these plans to the central pharmacy plan formulary lookup service. Most pharmacy benefit plans are managed by a small oligopoly of companies and a little diplomacy and arm twisting can get the job done very easily and quickly.
- The private sector has used some innovative tactics to encourage the use of generics, and the public sector would do well to learn from the trails they have blazed. After all, the private sector puts its own money on the line and unlike the public sector, will not throw good money after bad in some failed social experiment:
- Medco Health, which is one of the premier Pharmacy Benefit Management companies, created an innovative program they named Generics First, in which it distributed samples of generic drugs to physician offices, much like the “detail men” who work for the pharmaceutical companies. By encouraging the use of generics as the initial theraputic choice, Medco significantly increased utilization of generics.
- BCBS of Minnesota, dropped copays for generic drugs altogether from some plans and found that, in many cases, the savings from increased utilization of generics more than compensated for the cost of eliminating copays.
Physicians are primarily concerned with the health and well-being of their patients, and most of them will choose the medicine that will do the job effectively, with minimal side effects, at a price that the patient can afford. If the senators want to make this job easier, they can implement some of the suggestions listed above rather than spending our tax dollars on a massive education and outreach program that would be much less effective.
I also would mention the astonishingly inexpensive drugs than can be purchased without any insurance, without any plan or membership at Wal Mart. A three month supply of any one of 400 generic drugs costs only $10 (yes, in words, ten). It does not get much less expensive than this. No matter what you think of Wal Mart, this is a great service that benefits especially those with little funds and incomplete or no insurance!
I mention this to many of my patients, most of whom did not know about this bargain basement priced source. My mother in law started saving over $100 a month after she asked her internist to switch her from a more expensive brand name medication to one of the Wal Mart generics. Can’t beat it! It is phantastic! Everbody needs to know about it! Target, by the way, has an identical program
This article by Jose DeJesus MD is featured in Total Mind and Body Fitness Blog Carnival 43
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This article by Dr. Jose DeJesus MD was featured in the sixth edition of Drugs and Pharmacology
I hope that our Congresspeople read this.
I object to the way the Pharmaceutical Industry has sought to subvert the traditonal physician-patient relationship by directly addressing our patients and telling them to tell us what drugs they should be taking, and furthermore to tell us what diseases they have, followed by a litany of possible complications. I consider this demeaning and insulting. I also violently object to any such regulatory initiatives as are being proposed. Everyone wants to be the physician these days, except the physician.
C. W. Jones, M.D.
PROHIBITION AGAINST ANY FEDERAL INTERFERENCE.1801. [42 U.S.C. 139
In accordance to 42 U.S.C. 139. The federal government is prohibited from interfering with the practice of medicine and to dictate the medication a physician may prescribe for his patient is a direct interference. In addtion the fedral register Nov. 7 clearly states in its final rule that "we continue to believe that the beneficiary's treating physician--not any treating practitioner--is best situated to determine ``in need'' status, both because he or she is the primary caregiver and also is responsible for the beneficiary's overall care.”
Federal Register: November 7, 2003 (Volume 68, Number 216)][Rules and
Regulations][Page 63691[13.7.142 CFR §§426.400(c) and Sec. 426.500(c) “In this final regulation by clarifying that the certification of need can be in the form of a written order for the service in question or other documentation in the medical record, thus significantly simplifying the certification requirements. We have also removed the requirement that the practitioner predict that payment would be denied. However, we continue to believe that the beneficiary's treating physician--not any treating practitioner--is best situated to determine ``in need'' status, both because he or she is the primary caregiver and also is responsible for the beneficiary's overall care.”
[...] DeJesus MD presents Lowering Prescription Drug Costs posted at Physician [...]
Dr. DeJesus’ summary of this situation is absolutely correct. If the senators would review plans similar to Medco Health and BCBS of Minnesota, maybe they would realize they might be wasting taxpayers money. They HOPE the cost of the program would be covered by the POTENTIAL money it MIGHT save. This would not be evident for years. Training pharmacists and nurses to detail physicians about the use of generics doesn’t make sense. They would be puppets for the government. Let physicians do the job they are trained to do, enhance and guide the healthcare of people which includes prescribing medications that work, generic or new.
Physicians are intellegent enough to know that drug companies are advertising to recoup what they have spent on research, marketing and to earn a profit. Some of the newer drugs are of course better than the old ones but not all the time. It is only after the drug has been on the market for some time that we come to know all their side effects.
Suggesting that we should always use the old drugs, which of course may be cheaper but less effective, and avoid the newer drugs is against logic. We should let physicians decide when to use the old drug and when the newer one.
Legislation is not the answer.
Jose DeJesus MD delivers once again. Lowering Prescription Drug Costs is well-crafted.