Article published Monday, August 25, 2008
NOT WHAT THE DOCTOR ORDERED
Physicians face pressures from drug managers
Push to change prescriptions presents dilemma for doctors

By STEVE EDER
BLADE STAFF WRITER
http://toledoblade.com/apps/pbcs.dll...WS32/106231964

Dr. Jack Brunner and his staff spend countless hours each week answering the calls and faxes of Medco Health Solutions, Express Scripts, and CVS Caremark, three of the nation’s largest pharmacy benefit managers.

Pharmacy benefit managers, which have emerged as a force in the health-care industry during the past decade, coordinate prescription benefits on behalf of insurance plans and employers. They typically will help determine what types medication will be covered, monitor use of medication, handle prior-authorization requests from doctors, and assist with disease management.

But physicians such as Dr. Brunner say pharmacy benefit managers are adding burdens for doctors’ offices and hurting patient care.

“Most doctors don’t start people on medications because they like to start medicines,” said Dr. Brunner, a Toledo endocrinologist. “They have specific reasons and goals for the patient. Usually when you decide on the medicine it is because you think that is the best for them. You always want to give the best to every patient, whether they [are] off the street or a millionaire.”

Pharmacy benefit managers are hired by employers, unions, and others to manage drug benefits — and keep costs down — and their use has increased the last five to 10 years, said Charles Coté, spokesman for the Pharmaceutical Care Management Association.“Employers are looking for ways to provide their employees with the drugs they need while also keeping an eye on making sure it’s affordable,” he said.

Who decides?
Ultimately, the decision about what is covered by a health plan is made by the employer, not the pharmacy benefit manager, CVS Caremark said in a statement, because the firm simply administers benefits for health-plan customers.

“Therefore, the prescription benefit management services we provide do not interfere with the clinical decisions that may be made by physicians and prescribers,” the statement said.

But doctors say pharmacy benefit managers certainly appear to be interfering or at least creating hassles.

When Dr. Brunner writes a prescription and hands it to a patient, he sets off a chain of events and paperwork that often lasts for months or years, he said.

“What happens is you order a drug you feel is best for the patients for multiple reasons and then you get a letter back, saying, ‘Not approved. Fill out this form,’” Dr. Brunner said.

Other times, after months of having their symptoms controlled by medication, patients receive mailings from prescription benefit managers informing them they will save money if their doctors switch them to generics or different drugs.

The issue of safety
Dr. Brunner said the changes sometimes requested by prescription benefit managers simply aren’t safe for some patients.

“Most people want cheaper drugs. I understand that,” Dr. Brunner said. “Many times there’s very good reasons why you would stay with the more expensive drugs.”

Encouraging generic options and negotiating prices with pharmaceutical companies are some ways pharmacy benefit managers control costs, Mr. Coté said.

Doctors are pressured by drug manufacturers to prescribe their products and inundated with informational material, and pharmacy benefit managers can help balance that by promoting generics and lower-cost alternatives, Mr. Coté said.

An ‘unusual case’
Dr. Gary Gibson, who practices in Cortland, Ohio, about 25 miles north of Youngstown, became so frustrated with the demands of Medco that he filed a lawsuit in a Trumbull County court seeking compensation for the time his staff has spent navigating the company’s requests.

“It’s against the public health, and it is crippling office care medicine,” Dr. Gibson said.

In March, Judge Thomas A. Campbell called it an “unusual case” but sided with Dr. Gibson, ordering Medco to pay $187.50 plus 8 percent interest.

In its defense, Medco argued that the doctors are not required to respond to its requests.

“However, if the [doctor] does not, then the defendant will simply refuse to fill the patient’s prescription — not much choice to a physician sworn to assist his patients,” Judge Campbell wrote.

Medco, based in Franklin Lakes, N.J., manages pharmacy benefits for one in five Americans, handling nearly 560 million prescriptions last year. In 2007, Medco’s net revenues were $44.5 billion, with profits of $2.9 billion.

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