Mismanaged Care: Denying America Its Medicine
Fox News
8.05 a.m. ET (1638 GMT) February 24, 1999
By Marian Jones
NEW YORK — Last summer, Robert Lessman was
desperate. For several months, the San Jose, Calif., resident
had suffered with a superflu that hadn't responded to the
antibiotics his HMO doctor prescribed.
He turned to an outside
specialist, who prescribed him a
new antibiotic called Zagam.
His HMO reluctantly agreed to
cover it, and it worked.
But as soon as Lessman got
better, the HMO reneged on its
coverage of the drug and he again deteriorated. Almost
a year into his illness, despite trying substitute
antibiotics that were on the formulary — the list of
drugs a health plan will cover — Lessman is still too sick to return to work.
"I personally believe that I would have been back at work last September if my
HMO drug formulary had not interfered with the treatment I was getting from the
out-of-network specialist," Lessman said.
Lessman's tale is not just another HMO horror story. It
is part of a larger trend, in which HMO drug formularies
— used by virtually all managed care plans —
increasingly limit patients' choice of prescription drugs
and patients, especially the elderly, sometimes suffer the
consequences. As of last fall, 81 percent of formularies
imposed some kind of restrictions on medication,
according to a study published in the American Journal
of Managed Care.
During the fall of 1998 alone, formularies increased their
restrictions in seven leading areas of drugs, including
antifungal drugs, migraine treatments, antidepressants,
cholesterol reducers, alpha-blockers, anti-ulcer drugs
and calcium channel-blockers, according to a report released at the end of January
by Scott-Levin, a pharmaceutical consulting firm.
HMOs and pharmacy benefit
managers are increasing the use of
"restricted use" controls that can
require a prescription from a specialist
or limit the number of pills and "prior
authorization" — a requirement that a
doctor receive permission from the
HMO before prescribing a drug — as
formulary controls, the consulting firm
stated in a press release.
For example, 44 percent of
formularies restrict prescriptions for
Viagra, 45 percent require prior
authorization for a doctor to prescribe the anti-fungal drug Sporanox and 35 percent
restrict prescriptions for tablets of the new migraine drug Imitrex, the report found.
Managed care organizations claim that formulary restrictions are designed to limit
access to "marginally effective" drugs and to ensure that the best drugs are
available for a particular condition.
Restrictions are also based on safety considerations,
said Richard Fry, senior director of pharmacy affairs at
the Academy of Managed Care Pharmacy, an
organization representing managed care pharmacists.
"Restriction doesn't equal ‘you can't have it' —
restriction means ‘it's for those patients who really need
it; it's not appropriate for the entire patient population.'"
For instance, Fry noted, the restricted migraine drug
Imitrex "is contraindicated in patients with cardiac
problems, just like Viagra is."
But another chief consideration in the era of managed
care is cost. A recent study, though, found that
formularies are neither safe nor cost-effective.
In this study, published in 1996, Dr. Susan Horn, a
researcher at the University of Utah who has studied managed care formularies,
looked at the impact of formulary restrictions on 13,000 HMO patients in six HMOs
around the country.
Her research zeroed in on treatments for several common diseases including
arthritis, asthma, high blood pressure and stomach ulcers.
Horn discovered that the more a formulary
limited medications for these four diseases, the
more the patients visited the doctor, went to the
emergency room and had to be hospitalized for
their symptoms.
Restricting medications also caused doctors to
prescribe more drugs. In the most restrictive
plan, patients in Horn's study saw the doctor 83
percent more than those in the least restrictive
plan.
Even though Horn's research was paid for by the
HMOs themselves, who had hoped they would
find out that their restrictions were working, it
stirred up controversy in the already-heated
debate over managed care.
"Formularies are based on the principle that drugs in the same class are similar
enough to each other to switch patients from one to another, and that switching a
patient to a less-costly medication will definitely save money," Horn said. "What
we're finding is that that doesn't always happen.
Instead, many patients don't have the opportunity to get the drug that will keep
them well or get them better as quickly as possible, Horn explained. "So you end up
doing just the opposite of what you hoped to do."
Some managed-care experts have disputed Horn's findings.
Horn collected "no baseline data on what people's drug utilization and health status
was prior to the study," asserted Fry. "She also failed to track whether the patients'
health status declined because of the alleged restrictions on access to certain
drugs."
Despite these alleged flaws, Fry added that "Horn's study "gave us a bit of a
wake-up call that we needed to do more research in this area and [reminded us]
that we need to ensure that the formulary decision process is based primarily on
sound clinical considerations," not just on cost factors.
In the wake of these surprising findings, some
HMOs, such as the Loveless Health plan in New
Mexico, have since re-examined and revamped
their approach to health care management.
In the area of mental health care alone, Loveless
found that lifting its limits on medications actually
saved money in the long run.
The administrators at Loveless looked at 2,000
mental health patients in their plan, which had
cost them an annual total of $13 million to treat
under their former system of limiting medication
and mental health services. When the plan
switched the next year to a policy that
encouraged patients to seek mental health
treatment and actively recommended Prozac and
similar newer, expensive mood disorder
medications, the total cost for these patients
dropped to $11 million, Horn recounted.
"Of course, the cost of drugs went up considerably, but the patients' care was less
expensive," Horn said. "The patients were able to stay on the drugs more
appropriately, and they used other services less."
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