The recent news that Medicare will be restricting the choice of drugs doctors can prescribe has raised widespread concern among patients and doctors. In fact, this news is not at all surprising; drug choices are already increasingly restricted by the various health care plans. It is a serious concern. I'd like to convey my thoughts, reflecting my perspective as a physician, and specifically a hypertension specialist.
Clearly the goal of reducing the enormous cost burden of prescribed drugs is a legitimate one. If a drug that costs $200 a year is just as good as one that costs $2,000, restricting the latter makes sense. But the situation is not that simple.
Generic drug manufacturers are regulated and required to demonstrate rough equivalence to the branded drug. In general, physicians are comfortable prescribing generic drugs, and the cost saving does not conflict with good care, although regulatory vigilance is clearly a necessity. Some patients insist on the branded drug, and will not trust or even try the generic. Some others claim reactions to differences or to "fillers" in the generic drug; some are true reactions; some are not. Here, the physician may need to prescribe the branded drug; the higher cost may or may not be borne by the patient.
Different drugs from the same drug class
Here we are talking about substituting one drug for another within the same drug class. Examples of drug classes are beta-blockers, angiotensin antagonists, and many others. Drugs from the same drug class can differ substantially from each other. Bureaucrats who look at costs don't allow for these differences, or for the fact that different patients respond differently to different drugs.
When forced to switch to an "approved" drug, the right dose often cannot be predicted from the dose of the previous drug, due to differences in drug metabolism. Selecting the dose can be a guessing game, with consequences. Also unmentioned, most doctors tend to prescribe the drugs they are most familiar with, and whose nuances they know best. Restrictions force doctors to prescribe drugs with which they are less familiar.
Loss of underused terrific older drugs
A terrible, yet unmentioned consequence of restricted choices could be the loss of some terrific older drugs. These drugs are best known to specialists and to practitioners with decades of experience, and some of them are better than the newer drugs, but are lost in the avalanche of promotion of the newer drugs. Their value is not appreciated by health care plans or Medicare. Although they are older and generic, they can be expensive because their sales volume is much lower and few manufacturers produce them. Restrictions against their use will threaten their modest sales, with the likelihood that some of these truly great drugs will no longer be manufactured, and their use will be lost to us, permanently.
Here are a few examples of harmful consequences of recent drug restrictions. As I describe in Hypertension and You, I prefer prescribing a couple of the old beta-blockers that have important advantages over the newer best-selling one. They achieve a much more predictable blood level and effect. They also don't get into the brain, and in my experience are less likely to cause mental dullness. I don't want to prescribe the best-seller, but might have to.
A patient whose hypertension was uncontrolled on five drugs responded to my switching him to a newer more expensive angiotensin antagonist (ARB) that has been shown to be more effective than the other ARBs. The result: fewer office visits, reduction of other medications, and a reduced risk of future hospitalizations or stroke. I can no longer prescribe that drug to him. Penny-wise, pound-foolish.
The appeal process
When a drug I want to prescribe is rejected, I am of course invited to appeal the rejection, meaning a member of our staff must sit on the phone for a half hour or more (I assume the long wait is intentional, to discourage appeals) and/or I have to take the time to write an essay defending the use of the drug. Since so many prescriptions are rejected day after day, there is no way we can appeal every case we want to, and the drug plan administrators know that.
Although restricting very expensive drugs is certainly understandable and necessary, the impact on care of restricting drugs that are only modestly more expensive is less justified. Between patients changing drug plans, and drug plans changing their "preferred" drug lists depending on slightly better prices they negotiate with manufacturers, a patient's medication has to be changed, again and again. In this respect patients are being treated like pawns.
Another blow to patients occurred when the Medicare drug program was initiated under George W. Bush -- Medicare was not allowed to negotiate lower prices with manufacturers! The priority went to corporate profit, at the government's expense.
Recognizing that restricting drug choices has economic merit, and is necessary, are there ways to minimize its disruption and harm to medical care? Here are some suggestions:
1. Limit drug restrictions to instances where the cost lowering is substantial, rather than disrupting care for smaller differences in cost.
2. Streamline the intentionally time-consuming appeal process that greatly discourages appeals.
3. Reduce the volume of rejections and appeals, for example, by not harassing doctors who prescribe the more expensive drug in fewer than 5 percent (or whatever selected percentage) of their prescriptions.
4. If a doctor strongly believes that a restricted drug is better than the "preferred" drug and wishes to prescribe it regularly, allow the physician to submit a comprehensive letter, once. If the argument is valid, he need not be harassed each time he tries to prescribe it.
5. The grave threat of the permanent loss of valuable older drugs needs attention and action.
There are certainly other and better ideas. Hopefully cost-cutting, which is necessary, can be achieved with less harm to patients. Meantime, the unfairness of how drugs are restricted is a serious concern.
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