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Prescription plans: Friend or foe?
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Consider the following scenario — one, I might add, that seems to occur with increasing frequency.
OD: "You're absolutely correct, Mr. Vernal. It appears as though you have an allergic conjunctivitis. The good news is that it's fairly mild and not sight threatening."
Mr. Vernal: "Is there anything I can do to make it feel better?"
OD: "Yes, in fact, I'm going to recommend an antihistamine-decongestant eye drop. This medication is effective, has an excellent safety record and is now available over the counter (OTC)."
Mr. Vernal: "Actually, Doc, I was hoping you could give me something a little stronger. You see, my health insurance has this rider, and I can get any prescription medication for $4!"
We've all been there, trapped in this inevitable no-win situation. On one hand your clinical acumen deems an OTC agent to be perfectly appropriate and the most cost effective solution. On the other hand, your patient, feeling he is already paying outrageous premiums, wants to minimize his out-of-pocket expenses.
The best solution? Simply write a prescription for the OTC agent! In a perfect health care system this would work. Unfortunately, this is the real world. Often, the pharmacist's computer doesn't list OTCs among prescription options, or the insurance plan doesn't designate it in its formulary.
Given health care reform, I understand the need for prescription plans. As a rule, they are an effective means by which to monitor and modify prescribing habits, thereby containing costs. Unfortunately, when the aforementioned dilemma occurs, they seem to do just the opposite. In fact, there are numerous instances in which prescription plans influence patient behavior, and not always for the better.
For instance, prescription plans encourage "bulk refills" on chronic use medications. Fundamentally, this is a good strategy for enhancing compliance. However, will a patient return for a 4-month glaucoma check if he or she has a 6-month medication supply? And, if a change is necessary at this visit, what becomes of the remaining medication?
Prescriptions plans also foster the shift from label to generic. Again, an excellent strategy to curtail costs. However, patient perceptions of generics are not always favorable. Whether a reduced therapeutic index is real or perceived may be a moot point, particularly if the patient just stops taking the medication!
Finally, prescription plans often endorse a single pharmacy distribution. The insurance plan contracts with a competent, single-source pharmacy hoping for the best possible price. Unfortunately, in the process the time-honored patient-local pharmacist relationship is often undermined. Patients lose the opinion of a familiar, trusted and respected professional, an individual to whom patients turn for reaffirmation of dosing habits and information on possible side effects and adverse drug interactions.
So, how do you answer Mr. Vernal's request? You could:
- restate the fact that the OTC agent is the recommended option for this particular condition;
- comply with his desire and issue a prescription for something different; or
- just give the patient a sample.
The latter, of course, is a whole other editorial!