Who picks your drugs?
Sunday, June 6, 1999
By LINDY WASHBURN
Staff Writer
Margaret Falk's arthritis started a decade ago.
Her legs hurt so much, she sometimes has trouble
walking. Over the years, she has tried all sorts of
prescription drugs to fight the pain -- including
some that gave her an ulcer.
So she was surprised this spring to find that her
managed-care company wouldn't pay for
Celebrex, a new arthritis medicine her doctor had
prescribed -- one advertised as being easier on
the stomach.
These breakthroughs in prescription medicine
mean nothing to Falk and patients like her if they
can't get the drugs. And more and more patients
are finding that it's tougher to get such medicine,
even with insurance coverage.
"I got all the way to the drugstore, but no further,"
said the 49-year-old Northvale woman.
Controlling access to costly drugs is just one
tactic in increasingly aggressive campaigns by
most managed-care companies to contain the
runaway costs of prescription drugs, the
fastest-growing segment of health care
expenditures.
Having focused on hospital and physician costs,
private insurers are now zeroing in on prescription
benefits. Expenditures for drugs climbed a steep
22 percent in 1995, followed by 18 percent in
1996, and another 18 percent in 1997.
The result: More and more patients find the
medicine they receive is not what their doctor
initially prescribed.
Aetna U.S. Healthcare, the state's largest HMO
and the one that insures Falk, adopted a policy in
February that has made it harder to get new drugs
for arthritis and, coincidentally, ulcers -- two of
the top five ailments for which drugs are
prescribed. Before pharmacies can fill
prescriptions for new "second-line" drugs such as
Celebrex, which hit the shelves in January, the
patient must try at least two weeks on an older,
or "first line" -- and usually less expensive --
medicine. The policy is called "step therapy."
Aetna is not the only insurer to change the rules
on prescription drug benefits. In addition to
Aetna's step therapy, these measure are being
taken by many insurance companies to cut costs:
Three-tiered copayments. Horizon Blue Cross
and Blue Shield, Aetna U.S. Healthcare, United
Health Group, and Oxford Health Plans have
introduced policies that use three different
co-payments. The lowest is for generics; the
middle for brand-name drugs on the company's
preferred list, or formulary; and the highest for
drugs that are not on the company's formulary.
Typical copayments are $5, $10, and $25; or
$10, $15, and $30, with Oxford's top payment
going as high as $50. Experts believe most
prescription plans soon will have this structure.
Closed formularies. These plans, which are not
widely used in New Jersey, pay only for the drugs
on the company's preferred list; the patient pays
for non-formulary drugs.
Prior authorization. For very expensive medicines,
so-called "lifestyle drugs" such as Viagra, or those
that may cause serious problems when taken in
combination with other drugs, some plans require
the doctor to get approval before writing a
prescription. Plans sometimes limit the patient to a
30-day supply, with permission needed for a
refill.
Many insurers also require prior authorization
before paying for multiple sclerosis drugs, certain
types of insulin, and other specific drugs.
More headaches for physicians
Doctors say this micromanagement, by dozens of
insurers with dozens of different lists of preferred
drugs, is a waste of time. They say it's impossible
to keep track of all the formularies, and they can't
afford to look up each prescription they write.
They resent the constant calls and letters from
pharmacists or benefit managers asking for
substitutions.
Dr. Howard Rothman, chief of cardiology at
Englewood Hospital and Medical Center, opened
16 letters in a single morning recently from one
pharmacy-benefit company recommending that he
change prescriptions for 16 different patients to
lower patients' copayments.
"I have to put the notice in each patient's chart,
and in their next visit or prescription renewal, I
now to have spend time to address this issue,"
Rothman said. "Why should I do that for a
formulary choice that's economically driven, not
clinically driven? If a medication is succeeding at
keeping a woman's high blood pressure under
control, why fool with it, just because she
changed insurance companies?"
Dr. Sam Snyder, the orthopedist who prescribed
Falk's Celebrex, says he had noted her inability to
tolerate other medication during 10 years as her
doctor. "What is most infuriating is I have to take
my staff and have them call the insurance
company, spend 20 or 30 minutes on the phone
to get permission," he said. "Nine times out of 10,
it's denied."
Aetna defends its policy, noting that Celebrex's
claims about causing fewer stomach problems are
not yet approved by the Food and Drug
Administration. Raphael Tancredi Jr., the
company's director of pharmacy for the
mid-Atlantic region, says cost should be a factor
in choosing among medications that are otherwise
similar.
Older drugs, he said, will usually cost both the
member and the company less. If those work,
that leads to significant long-term savings --
savings that go toward keeping health care
premiums under control, he said.
But patients are often confused: They think their
prescription-drug coverage means they will be
insured for whatever their doctor prescribes.
"I don't understand that restriction," Falk said.
"They flat-out refused to fill my Celebrex
prescription." She returned to her doctor to get a
prescription for Naprosyn, which she asked the
pharmacist to fill while she made do with
Celebrex samples from Snyder.
Pharmacists, of course, are caught in the middle.
"We bear the brunt of the anger," said Matthew
H. Kopacki, who owns the Rock Ridge
Pharmacy in Glen Rock. "I'm the one who gets to
say, 'I'm sorry, it's not covered. That will cost you
$87.' "
Managed-care companies say their careful
attention to prescription drugs has a flip side:
They're watching for underuse of drugs. If a
doctor is not prescribing proper medication for a
patient with hypertension or congestive heart
failure, these HMOs will point it out and urge the
doctor to change his habits.
Cost-cutting harms patients, doctors say
Increased spending on prescription drugs is a
logical outgrowth of better health care, experts
say, as research advances and pressure increases
to reduce hospital stays and surgery. Spending on
inhaled steroids to control asthma saves money
on emergency room costs. Drugs that slow the
worsening of multiple sclerosis symptoms reduce
the number of hospitalizations for MS patients.
Control of cholesterol may slow the clogging of
arteries, postponing or eliminating the need for
costly and risky heart surgery.
One study, published in The Journal of Managed
Care in 1996, found that when more restrictions
were placed on prescription drugs, patients got
sicker, spent more time at the doctor's office or
hospital, and needed other drugs.
"From the patients' perspective, increased use of
health care services means greater inconvenience
and longer periods of illness and discomfort," said
the lead researcher, Shirley D. Horn of the
Institute for Clinical Outcomes Research of the
University of Utah School of Medicine. She is a
medical statistician who was on the faculty of
Johns Hopkins University in Baltimore for 24
years.
So a managed-care plan, then, must strike a
balance that makes effective drugs available while
containing health care costs, the experts say.
But doctors have doubts about cost-cutting for its
own sake and question whether the full medical
consequences of some decisions are being
considered. They are particularly concerned when
they are asked to switch to drugs that are
equivalent -- but not identical.
Some drugs, such as anti-seizure medications
used by epileptics, are absorbed into the body
differently, and the correct dosage of a substitute
must be recalibrated through trial and error.
Doctors wonder whether a seizure that occurs
while a patient works out the right dosage of the
new medication is an acceptable consequence of
saving the insurance company money.
Other drugs may be similar in terms of their
primary effect -- lowering cholesterol, for
example -- but different when it comes to
secondary effects, such as changing the way
blood clots. A careful doctor will want to
consider those secondary effects when choosing a
medication, Rothman says.
Some doctors don't trust studies that measure the
effects of a natural form of a drug when they will
prescribe its synthetic form. Or they find the data
"proving" equivalency to be weak. Financial
considerations -- rather than scientific rigor --
may have swayed the managed-care company,
they contend.
Even more important is that doctors build up
hands-on experience with certain drugs over time
and become familiar with their side effects and
efficacy, said Dr. David Swee, who teaches
family medicine at the University of Medicine and
Dentistry of New Jersey's Robert Wood Johnson
Medical School. If they constantly switch among
a dozen different medicines of the same type, they
won't have that opportunity.
But Paul R. Langevin Jr., president of the New
Jersey Association of Health Plans, dismisses that
argument. "A physician has to make a concerted
effort to go out and learn about other drugs," he
said.
The struggle to contain drug costs, Langevin said,
represents the larger dynamic of today's health
care system.
"We're trying to align incentives for members,
physicians, and health plans in the same
direction," he said "Everybody has got to work to
keep costs down." Physicians and patients must
understand the cost of their choices and decide
whether the benefit is worth spending more, he
said.
FDA collecting reports of ill effects
As the switching of drugs to satisfy a
managed-care company has become more
common, the FDA has begun to monitor possible
adverse consequences. So far, says Laurie
Burke, branch chief for the division of drug
marketing, "The jury is still out."
The agency began soliciting reports from health
care providers about problems in March 1997,
and by the end of that year had collected 108
reports, she said. It is impossible, she added, to
estimate how widespread the practice is.
None of the problems reported to the FDA
resulted in death. Nearly half were in people over
age 65, and about 10 percent led to
hospitalization or other medical intervention. The
most common problems reported were for proton
pump inhibitors -- prescription antacids.
In some ways, New Jersey has been insulated
from the most restrictive drug-benefit policies
because drug manufacturers are among the largest
purchasers of health insurance in this state. To
them, free access to drugs is an article of faith.
The Aetna U.S. Healthcare prescription plan that
excludes coverage for certain drugs is least
popular among four choices available in New
Jersey, Tancredi said. The company insures 1.7
million New Jerseyans, 770,000 of them with
drug coverage.
"We actually don't like formularies," said David
Knowlton, president of the Health Care Payers
Coalition, which represents the purchasers of
insurance for 600,000 union members and other
workers. "No drug is identical. . . . When the
formulary is imposed based on cost
considerations, rather than clinical considerations,
we have a real problem."
Although some states have passed laws requiring
managed-care plans to disclose which drugs are
on their formulary and how exceptions can be
made, New Jersey has not done so.
Nevertheless, the New Jersey Association of
Health Plans this year published a guide for
physicians, comparing the formularies of nine
major managed-care plans.
Few complaints have reached the state
Department of Banking and Insurance about drug
coverage, and no company stands out as a target
of complaints, said spokesman Bill Heine.
The state Board of Pharmacy has not addressed
the issue of switching drugs, and simply requires
that pharmacists obtain the permission of the
prescribing doctor before substituting one drug
for another.
Copyright © 1999 Bergen Record Corp.
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