Sunday, July 24, 2011

Pharmacy Benefit Managers vs Physicians: Let the Games Begin!

As a gastroenterologist, I treat hundreds of patients with heartburn. You already know the names of the medicines I prescribe, since they are advertised day and night on television and appear regularly in print newspapers. Pharmaceutical representatives for each one of these drugs come to our office each claiming some unique clinical advantage of their products over the competitors. They have a tough job since the medicines are all excellent, are priced similarly and are safe. On some days we will have 2 or 3 reps visiting us, each one proffering a medical study or two that supports their product. They show us graphs where their drug is superior to the others regarding an event of questionable clinical import. Their goal is to show that the graph line of their drug is going up, while those of their competitors are going down.

Physicians, like me, who do give these folks some time, have mastered the art of the slow head nod as the drug’s virtues are being related. In the past, the relationships they cultivated with us translated directly into prescriptions being written. Not so today, when our prescribing pens are controlled by insurance company formulary requirements. Those drugs that are not on the coveted list not just swimming upstream, they’re trying to scale a waterfall.

Drug companies know a lot more about us than we know about them. They have detailed prescriber information about what we are prescribing to our patients. Though I assume they don’t have specific patient identities, they purchase date enabling them to know how much Nexium, for example, I am prescribing. This information is used by the companies to motivate their reps. “Kirsch is prescribing Nexium to only 20% of his reflux patients. We need him at 30% by the end of the year.” Drugs reps, who are hired for their extroverted personalities and communication skills, become tongue twisted or even mute if this issue is raised with them.

One of physicians’ most exasperating waste of time is handling calls from pharmacies that the heartburn drug we prescribed isn’t the ‘preferred medicine’. There is no way that a busy medical practice can keep track of the drug coverage preferences for every insurance, company, particularly since these lists change regularly. When the pharmacy calls us, we have to review the record and then change to the new drug, if this is medically acceptable. This takes an enormous amount of time, clogs up our phone lines and doesn’t seem to improve any patient’s health. The real fun starts when we try to convince a pharmacy benefit manager (PBM) to authorize a medicine that is not on their magic list. The phone calls and paperwork are designed to discourage all but the most dogged doctors from pursuing the request. Doctors who enter this arena must relish the thrill of combat if they are to have any chance to prevail. Of course, the PBMs have the leverage, but skilled and seasoned medical professional can pierce their armor to achieve a Pyrrhic victory.

On those occasions when I triumph over the PBMs, I bask in the glow of victory. But, no victory is total. At the end of these setbacks and skirmishes, guess who needs the Nexium most?


  1. I am fortunate that my EMR (EPIC) incorporates the preferred lists into the pharma database for each patient based on their insurance info, so if that is up to date, then as I am typing in the drug name, the "preferred" drugs are green and others others red.

    Has probably changed my prescribing habits more than any rep ever did.

  2. Excellent Post, thanx for sharing the same.. Will keep on reading the post.

  3. In primary care, add to PPI's...

    Quinolones (if its not ciprofloxacin)
    ADHD meds (if you want once daily dosing)
    Statins (if they you need greater reduction than the generics offer)
    Any albuterol inhaler (since they went CFC-free)
    Any branded SSRI
    Don't forget the one off's that require prior auth/step-edit like Singulair or Provigil

    As for formularies in the EMR...
    - it comes up on less than half our patients
    - validity is questionable (lisinopril red?? really??)
    - even the 'ok' ones sometimes get rejected when there's a step-edit, but the prescriber doesn't know it at point-of-care
    - formulary only matches when you are starting a new med, refilling is rolling the dice if the patient changed insurers or the insurers formulary changed or if it's been a year since you last jumped through the flaming hoops of prior authorization

  4. I am the mother of a child who had been on Norditropin for a year - He finally went from minus three percentile to fourth percentile - during that time we switched from Aetna to a good UHC plan to a relatively poor UHC/Oxford plan

    He has not had any growth hormone since April when I called for a refill and Prescription Soultions told me Norditropin is not covered and it would be over #2,000 - did I want to refill it? Confused - I thought it was a mistake

    I called Nordicare, the endocrinologist, Oxford, Medco - First, Medco/Oxford forces me out of Premier Kids Care and into Prescription Solutions (I could think of a few choice names for them none of them specialty pharmacy related)

    The long and short of it - pharmaceutical companies and insurance are quite a scam - Oxford moves brand names down to Tier 2 and generics to Tier 3 - Have preferred meds so that you are forced to switch, get retrained, -

    Where can we complain? Where is oversight?