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 Cot<0x00E9>, 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.
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. Cot<0x00E9> 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. Cot<0x00E9> 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.
The business practices of pharmacy benefit managers, who first appeared more than 30 years ago, have been under fire during the past decade. Some have paid tens of millions of dollars to settle lawsuits.
Earlier this year, Express Scripts Inc. agreed to pay $9.3 million to 27 states, including Ohio, to resolve lawsuits claiming it deceptively encouraged doctors to switch patients from one brand-name drug to another with the understanding that the change would save the patient money.
The lawsuit asserted that doctors weren’t given adequate information about how much savings would be passed on to patients and health plans.
The push to switch patients’ prescriptions for cost savings has posed dilemmas for physicians.
Last year, Blue Care Network of Michigan, a nonprofit HMO, offered primary-care physicians a $100 payment for each patient in their practice who filled a prescription with a Blue Care Network pharmacy for a generic cholesterol-lowering drug. In the letter dated Feb. 1, 2007, Blue Care Network included for doctors a report of their patients on Lipitol, Lescol, and Lescol XL at a dose the HMO considered appropriate for switching. It also included a dosing conversion chart and a pharmacy brochure detailing how much money would be saved by making the switch.
An opinion from the American Medical Association said there are “ethical concerns” with doctors receiving payments in exchange for switching a patient to a generic. The association’s opinion is that doctors’ financial interests shouldn’t be part of the equation when determining a treatment plan for their patient and that any incentives to the physician should be disclosed to patients.
Helen Stojic, a spokesman for Blue Care Network, said incentive programs for generics are commonly used to encourage physicians and patients to take lower-cost alternatives to brand-name drugs.
“The program was voluntary, and it really is something that helps address the facts that there are many businesses out there that are telling us they can’t afford prescription drugs for their employees,” Ms. Stojic said.
The Medicare dilemma
Where the financial realities of patients often come into play is in managing the care of patients on Medicare Part D, where prescription benefits only cover so much.
Dr. Thomas Freytag, a family physician in Wapakoneta, Ohio, for 27 years, sees many senior citizens who are insured through Medicare Part D.
When the federal government rolled out Medicare Part D in January, 2006, many greeted it with rave reviews, Dr. Freytag recalled.
“If it sounds too good, it probably is,” he said.
Dr. Freytag saw firsthand the shortfalls in the design of Medicare Part D. He treats a growing number of patients who reach their yearly prescription drug limits long before the year ends, sometimes as early as June. Once patients reach that limit, known as the “doughnut hole,” they are responsible for paying for their own prescription drugs.
So Dr. Freytag, looking to treat his patients while taking into account their financial limitations once they have hit their caps, prescribes cheaper generic drugs that patients often can buy for $4 at places such as Wal-Mart - even if a more expensive brand name drug may be better for the patient.
“It comes down to either taking the medicine or not taking the medicine, so if I can get it less costly, I’ll get them the $4 generics,” Dr. Freytag said. “If there are [drugs] that can’t be gotten that way, then those are the ones they submit to Medicare.”
Doing their best
Dr. Freytag believes he is doing the best he can for his patients, given their financial limitations.
But prescribing a patient’s second or third-best option is tough for some physicians, such as Dr. Elena Christofides, an endocrinologist from Columbus.
“[Doctors] get so beat down that they convince themselves that they aren’t hurting the patients,” Dr. Christofides said. “They aren’t fighting the fight because they feel they’ve done all they can do. They feel defeated.”
The struggle to get patients the medication deeply affects Dr. Christofides.
“That’s what makes me lie awake at night - the fact that I can’t help these people, but I can,” she said, adding, “Every day that I can’t get them their medication, I’m hurting them.”
Blade staff writer Julie M. McKinnon contributed to this report.
Contact Steve Eder at: firstname.lastname@example.org or 419-304-1680