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Prescribing medication in the climate of health care reform
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Many of my family members are health care providers. Seven, soon to be eight, are optometrists, but there are also a few physicians and a new speech pathologist in the fold. As you can imagine, dinner table discussions often center around health care issues. With the recent Thanksgiving family holiday, a number of issues were discussed that are worth noting.
First is a story from my physician brother who, as a young doctor, wanted to do some charity work in a medically underserved country. He went off to India for a month and was sent to a rural clinic to provide free primary medical care. He came home rather dejected because he learned that you cannot treat poor people with free medicine if they step right out of your clinic and sell the medicine to buy food for their family.
The second discussion was led by my oldest optometrist son who was taught that a new doctor should always prescribe the latest and greatest of ophthalmic drugs. He had written for a few of these new designer drugs and then scheduled the patients for a 1-month follow-up. He was stunned to learn that his patients did not fill his prescription because the drugs were just too expensive. They also did not call the office to discuss the issue, but rather just went untreated.
These stories serve to support one of my pet peeves with my optometry colleagues. I have always been a champion of using the tried-and-true ophthalmic medications rather than testing out every new medicine that comes down the road. Unless the drug is in a new class or provides some unique and measurable advantage, I use the traditional medicines.
At a recent meeting of optometrists, I conducted an informal poll regarding the use of two certain popular drugs that are heavily marketed to optometrists but when closely scrutinized are tested to be only “as effective as” the long-standing “gold standard” drug in their class. These drugs also happen to be almost 10 times the cost of the traditional drug that is even available in generic form. The poll showed that more than 90% of the doctors I surveyed routinely prescribed the new drug. When asked why, most said that that the pharmacological representative had told them that it was “better” and that all of the big-name docs were using the new drugs. Of course, their friendly representative also brought donuts, and that certainly did not hurt the cause.
In this era of health care reform, patients are sensitive to all costs relating to health care. Optometrists should pay close attention to each patient’s health care coverage and try to work within the plan’s established clinical guidelines. This would include a review of the health plan’s drug formulary and prescribing accordingly whenever clinically appropriate. Patients who do not have a drug plan are even more sensitive to the cost of their medications. Patients will need a compelling reason to use a more expensive medicine if a lesser-cost alternative is available.
My last tale really drove this point home to me. I was treating a patient with mild chronic allergic conjunctivitis. I had tried several options and finally found one that resolved the problem. After a month, I got a call from the patient asking for a renewal for the previous medication that had been less effective. When I called back to see if a problem had evolved with the more effective drug, the response came as a bit of a surprise, even to me. The patient said, “I really liked that new drug, and it sure solved the problem, but it is so much more expensive that I can stand a little bit of the irritation that I had with the other drug.”
Today’s primary health care optometrists will need to take a more comprehensive approach to prescribing medicines. Your patient’s health plan and the cost of the treatment need to be part of your equation.