One of the major tasks of doctors is prescribing the correct medications to patients. After discussing options with patients, a treatment plan is devised. But, it becomes a mere wish as the insurance company over-rules that decision. All too often, the medication is not part of an insurance company’s formulary and it is too expensive for the patient to pay out-of-pocket. So, who decides these formularies?
As the prescribers, it seems reasonable that doctors would lead the formulary making process. We are the ones who know what is best for our patients. However, we are usually left out of these decision trees. We may have patients doing well for years on the same medication but that is no guarantee that they can continue on it. I have seen too often patients forced to change appropriate medications because of formulary changes. To appeal the insurance companies’ formulary decisions require a great amount of time and effort. And all too often this is wasted time and effort. Doctors’ frustrations intensify under this system because we feel that we are not able to give the best care to our patients. Most doctors do try to keep healthcare costs in mind. But keeping costs down is not always the best treatment for patients.
Pharmaceutical companies are big drivers in what medications get covered. Much lobbying goes into getting their medication listed. Sure, they have studies showing good outcomes with their products. But, they are not always the best outcomes or the only ones with good outcomes. Pharmaceutical companies have a big conflict of interest in helping create formularies because they directly profit from favorable decisions. More head-to-head studies are needed.
Hospitals often devise their own in-house formularies based on cost. This too exerts some influence on insurance formularies. Hospitals see shrinking profits and look for every way to cut costs. This cost reduction derives some benefit from cutting costs on medications used in the hospital setting. Again, there is some conflict of interest here because hospitals increase their profits by deciding what medications they will carry. This is based on dollars and not patient outcomes.
Insurance companies also have a conflict of interest deciding their own formularies. Their profits are maximized when they cover the least costly medications, not necessarily the best medications. I have had prescriptions rejected and asked to prescribe a completely different class of medication instead. This decision has no basis in patient care or trying to help ease patient suffering but merely in cost savings. Insurance companies have no oversight in devising these formularies. They are completely free to chose and reject any medications they wish.
Much power in making medical decisions has been grasped out of doctors’ hands. The ability to prescribe the best medication for our patients is one example. There is nothing more frustrating for a doctor than to feel that we are able to give our patients better care but are unable because the insurance companies stand in the way. Further, we know many of the formulary decisions are decided by non-doctors with ony cost-savings as the end point. Clinicians need to have more input into these decisions and improved clinical outcomes need to be the goal. We own some of the best medications in the world, but how will they help if we are prevented from using them?
Copyright secured by Digiprove © 2015 Linda Girgis, MD, FAAFP
