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« April 2014 »

"It's in the best interest of...."Part 2

\Well, I didn't in fact die from a brief rhinoviral infection. And the state troopers never knocked in my door to confiscate my 48 pseudoephedrine tabs, although I did feel that the camera at the pharmacy window was watching me a little closely. Lucky for me I didn't need an antibiotic. Knowing my doctor, he would have prescribed one that really works well, but is also expensive and likely restricted by my insurance company. And now we get to an issue that really gets my blood flowing - formulary restrictions. Look, I am pleased that pharmacies, like my hospital pharmacies, sometimes "bother" me with a call or alert that I have chosen something that could have an interaction or even to remind me that there is a generic "equivalent" of some drug that could save my patient some money. Being middle-aged and overweight with a significant family history of heart attack, my doc wisely put me on a statin when my cholesterol was borderline high. It worked great. A couple of months later, my wife said she got a notice from our mail-in pharmacy that another statin drug was significantly cheaper. Like $30 a month in copay cheaper. So I asked my doc if these drugs would be equivalent for me. He said yes, and now I spend the $30 a month on other things, like tennis lessons, which are also good for my heart. Problem is, we all know that medication equivalence is a tricky subject. We all have patients who respond to one SSRI, but not to another. I can't tell you how many slides, papers and book chapters I have written quoting a study showing that nifty little fact. And then there are sometimes specific indications for one drug over another. Patients with post-stroke depressions probably should have a TCA. Patients with chronic pain and depression should probably have a TCA or SNRI. SNRIs are often better tolerated than TCAs, so maybe they should be first-line for these patients. But try to tell that to an insurance company. Now we have two issues that are huge pet-peeves of mine - restrictions set based on cost alone without good science to back them up, and pre-authorization. I've already said why I hate cost-based restrictions. I like suggestions, like for my statin, but restrictions almost make me want to prescribe only the most expensive meds and inundate the companies with prior-authorization forms. Almost. I was nearly overcome with violent rage when I heard in a public forum meeting (Mr. Hummel and others from the MPS were present) one insurance representative say that his reviewers knew more about managing medicines that doctors. And he said it twice, at the request of the state legislator who asked him to repeat it to be sure he had said something so outrageous. We worry about psychologist prescribing without adequate training, but this is worse, in my opinion, because these folks aren't trained and aren't even seeing the patients. And then there is pre-authorization. I see a patient. I make a diagnosis with the patient. I carefully choose a medication, based on all applicable factors. I write a prescription. The patient takes the prescription to the pharmacy (which hardly happens anymore, since now my scripts are electronic). And an hour later, the pharmacy calls me saying I need to get pre-authorization since the medicine is "second-tier" or some such nonsense. In some instances, I have to call the insurance company to get the form faxed to me, which has to be filled out with all of the patient's demographic information and a rationale as to why I want the medication that is supposed to include demonstration of failure or intolerability of several "first-tier" drugs. Try this exercise - replace "second-tier" and "first-tier" in the preceding sentences with "expensive" and "cheap" and see how it feels. All this causes delays and wasted time. And try this when the patient doesn't fill the prescription right away, and the pharmacy calls you a few days later and you don't have the patient's chart because now you're at your other office. The point is, we have many levels of monitoring. The cost-benefit analysis of installing a monitoring program or restriction-style program should be carefully considered. And the bottom line in those considerations should be "This program is in the best interest of who?" Patients?  You bet. Public health and safety? All for it. Protecting the insurance companies’ investment portfolios or state dollars that will be spent on private interests? Well, I think my heart rate is up again, and I haven't taken any pseudoephedrine in a month.


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