Formulary Mangement: Just to Rake In Profits?
Pharmacy Benefit Managers (PBMs) such as ExpressScripts, OptumRx & Caremark continue to raise new hurdles to patients who need medicines that don't meet these companies' cost-saving goals. Patients are forced to change to different drugs, often annually, by different pricing "tiers", requiring a trial of an approved drug ("step therapy") before allowing an alternate medicine, and creating other administrative chores. USA Today found that these companies that create the red tape for doctors & patients are posting record profits, even though there is doubt that their formulary management actually saves money. Independent pharmacies have called attention to questionable PBM practices.
A position paper from the American Glaucoma Society describes the difficulties Formulary Management causes both patients and doctors:
Because each drug plan formulary is different, this information is often lacking to both the physician and patients until the patient presents their prescription to their pharmacist... Pharmacists, however, have direct patient-specific access to tier-level copay amounts, deductibles, drug plan prior authorization fax numbers and addresses, while physicians do not. This limits our members’ ability to counsel patients about drug costs and restrictions.
Step-therapy often requires multiple interactions with the drug plan on the part of the physician to provide records, sometimes from many years prior, to prove to the plan that the patient has tried and failed a particular therapy. During this time-consuming process, the patient is denied access to needed medications.
A particularly troubling feature of formulary management is the ability for drug plans to switch tiers for their drugs on a yearly basis. The most common scenario is for brand name drugs within the same class to be moved back and forth from one tier to another, presumably due to the negotiated costs and rebates of the drug. The workflow cost to an insurer making a formulary tier change within class is negligible, while the cost to a physician’s practice is high. Managing phone calls from patients and pharmacists who want to avoid the higher copay or are concerned about a change in medication, rewriting and authorizing prescriptions, and educating patients and fielding their questions about a medication change and potential side effects is time-consuming and costly to a practice, while achieving no real benefit for the patient. In addition, if a change in medication is made, patients must return to the office for an earlier re-evaluation, increasing health care spending (often more than the price differential to the pharmacy plan).
As more people become insured under the Affordable Care Act, PBMs will become both more profitable and powerful, which could thwart efforts to keep drug costs down, according to USA Today.
