Mismanaged Care (cont'd) Restrictions May Hurt Oldest Patients Most
In the last couple of years, as the government began to
encourage retirees to switch to managed Medicare plans,
Horn decided to look at the effect of formulary restrictions
on this especially vulnerable group of patients. She
suspected the elderly, due to their greater use of medication,
were bearing the brunt of the restrictions' impact.
Horn's hunches were right,
according to her findings. In
this latest study, published in
the August 1998 American
Journal of Managed
Care, Horn found that
restrictions on drugs for
arthritis, high blood pressure
and stomach ulcers affect
the elderly more severely than younger patients.
When she looked at the same group of 13,000
patients in the six HMOs from her first study,
comparing patients over age 65 to non-elderly
patients and those in more restrictive plans to those
in less restrictive ones, the only time that the
restrictions didn't cause the elderly to suffer more
was in treatment for asthma, a disease that tends
to affect younger people.
There were several reasons that older people were more severely impacted, Horn
said. "The elderly often respond to drugs less predictably due to age-related body
changes, and any elderly patients need multiple medications because they have
multiple diseases and symptoms requiring treatment," she explained, and that means
they are at a greater risk for adverse reactions and significant drug-drug
interactions.
Managed-care proponents also disputed Horn's
findings in this second study, noting it was based
on stale 1992 data originally published in the 1996
study and that Horn failed to show a direct
cause-and-effect relationship between formulary
restrictions and greater use of health-care
facilities by the elderly.
In a letter to the editor of the American Journal
of Managed Care, Judith Cahill, the executive
director of the Academy of Managed Care
Pharmacy, also pointed out that HMOs do allow
doctors to prescribe drugs outside the formulary
when patients need them.
"A physician merely needs to call or submit a
request to the plan to gain this approval, usually within 24 hours to 48 hours," Cahill
wrote. "To say that formulary restrictions cause problems for the elderly is to
ignore the fact that doctors are responsible for providing appropriate therapy for
their patients."
Even if HMO physicians can and should make exceptions, Horn found in her
research that these doctors stick with the formularies 96 to 98 percent of the time
— just as Lessman's original doctor stuck with the ordinary antibiotics on his plan.
This could be because doctors are lazy or too overburdened to apply for an
exception. In some cases, though, the HMOs put up roadblocks that the physicians
may hesitate to tackle, Horn said.
For example: A doctor may want to switch a
patient from the ordinary antibiotic doxycycline,
which Lessman was originally prescribed for his
superflu without success, to a more expensive,
newer antibiotic that has met with less resistance
— just as the out-of-network doctor did For
Lessman. But Horn said "sometimes the
formulary requirement is you have to have failed
doxycycline three times in order to apply for prior
authorization."
The response of the managed-care system to
this? "If a physician feels strongly enough that
the patient needs to be on that particular drug, the
health care systems have policies and procedures
in place to make sure that that this can happen,"
Fry said. "The physician can act as the patient's
advocate."
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