If you’ve been following along with me on HR 676, the Medicare for All bill, we are now at Section 205, Payment for Prescription Medications, Medical Supplies, and Medically Necessary Assistive Equipment. Even more than payment of physician and hospital costs, the problem of medication and device coverage is incredibly complicated. I could spend a year blogging just about that one topic and still not get to everything. The more I think about it, the more amazed I am that this bill manages to cover the whole thing in four concise paragraphs.
Here’s the meat of it: prices to be paid by our national insurance will be negotiated annually; there will be a prescription drug formulary to “encourage best-practices in prescribing and discourage the use of ineffective, dangerous, or excessively costly medications when better alternatives are available”; generics will be promoted but use of brand-name and off-formulary medications will be allowed; and both clinicians and patients can petition their regions or the Director to add or remove drugs.
I hope you all know what an error it was to prevent Medicare from negotiating drug prices. A person unfamiliar with the deep grasp of corporate money on our political system could probably infer it from just this one flagrant dereliction of duty to citizens. The result? Needless waste of our Medicare money on overpriced products. We know this, and even so, it is unlikely to change any time soon.
That provision seems obvious. The formulary, though, strikes me as fascinating and different from other plans I’ve seen. Any of you who have insurance, public or private, have a formulary—a list of medications covered by your plan. There are a variety of approaches to limiting the use of expensive treatments. Many policies have “tiers” – a preferred list of drugs we can buy for cheaper co-pays, and one or two additional lists of drugs available at higher cost-sharing. Sometimes the first tier drugs are actually better and cheaper generics, but often they are just the ones your particular insurer got a better deal on. These negotiated deals are bundles—drug companies will offer packages to insurers where they give deep discounts on certain medications in order to get preferred treatment on the big ticket drugs.
Because the packages are all different between insurers, it means that patients switching from one employer to another often have to change their long-standing medications. I’ve told you about one such case I had recently, when an insurer insisted it would only cover one asthma controller medication for my patient—to which my patient happened to have a life-threatening allergy. I was finally able to convince them otherwise but it took a lot of back and forth. Usually there is a process to appeal these decisions, often with inordinate amounts of fax and telephone time, and there is nothing to say they have to give a final decision that makes sense.
There are also always medications the insurer just will not cover under any circumstances, and these vary from plan to plan. This seems to have nothing to do with medical effectiveness and everything to do with what they can get away with—the target patients are often those less likely to stand up for themselves, such as addicted people or the mentally ill.
It has been the general consensus that without such restrictions, docs will just willy-nilly bust the bank—that we are so much in the hands of drug reps that we are no longer capable of wise prescribing. Did you notice there is no restriction in HR 676? There is just encouragement and discouragement. Unless the Program chooses to add to that in the regulatory process, there would be no teeth here of the type we are accustomed to. Because there is no cost-sharing, patients would not pay more for inappropriate or excessively costly drugs. I suppose it is possible there would wind up being some of those ghastly “incentive” programs for physicians, but I hope not.
Possibly the ability to negotiate prices would be all that is needed – we could just simply refuse to pay more than a drug is worth, so that drug companies would quit wasting our time and money. Can we trust doctors enough to use good sense in prescribing—pick the more effective generic and leave the “me-too” brand-names alone? Is there any additional provision that would help strengthen the “encouragement”?
I think there are a few. Accurate public and physician information tools, feedback on prescribing habits, and inclusion of certain OTC medications in the formulary.
Carrots and sticks are not effective tools for higher-order decision making. In my experience, many patients (and even some doctors) translate the higher prices for second tier medicine and the extra hoops into a belief that these hard to get products are better. Anything that takes so much time and effort must be worth it, right? So even though constructing some sort of barrier to overspending is quite tempting, I believe it ultimately costs us more. What does help people make better decisions? Honest feedback and trustworthy, unbiased information.
Along with reforms of the FDA (a topic for another post), we need more effective patient and physician education resources untainted by sneaky drug company advertising. It would be very possible to design such tools so that we could all know the best available information on what works and what doesn’t. Doctors who have a pattern of prescribing outside the fold could be closely observed—and not just in a heckling sort of way, but with a curious, open approach. Because maybe their patients are doing better—maybe they know something we need to know. Or maybe they need to update their education.
Instead of basing payments on various grading systems as some insurers now do, we could try simply providing feedback to physicians on their prescribing habits and cost-effectiveness compared to national benchmarks. I get charts like that from a couple of insurers, and even though the data doesn’t change my salary I do pay attention. Once I saw that Medicaid had to pay more for one brand name asthma medicine than for another with the exact same active ingredient (remember this varies per plan), and because I don’t like to waste our money, I quit using the higher priced product for that insurer. Most of us don’t like to be extreme outliers and will adjust our practices accordingly. But the information needs to be presented in a truly useful way—right now, I have one patient with a genetic disease whose single expensive prescription from the specialist skews my data so much that I have no idea where my numbers really are anymore.
Including certain OTC medications in the formulary, just as Alabama does for Medicaid, would be essential. I’d like to see that provision specifically stated in the bill. Many patients in my practice ask me to switch to a prescription drug when their previously effective treatment goes over the counter, because the co-pay is cheaper than the OTC price. There is also a certain placebo boost that goes with that prescription signature. Including OTC coverage for selected items would remove a fair amount of prescribing pressure.
I can imagine a scenario like this: you have arthritis, and you visit your doctor to find out what to do about it. Once you have the diagnosis, you check the patient information portal with our national health plan and learn that OTC drugs like ibuprofen are just as effective as some of the expensive newer prescriptions. You learn that in your particular case, with no increased risk for stomach bleeding, there is no reason whatsoever to start with a brand name drug. Your doctor knows that too and what’s more—she knows you know better than to go by the deceptive advertising. She also knows that even if you are on a very limited income, you are able to get the ibuprofen covered. So she recommends a trial of ibuprofen along with diet changes and exercise, educates you on possible side effects, and lets you know there are other options if needed.
For my friends who worry that a single formulary would restrict their options excessively, I hope you are impressed by the wording in this bill. It is more open-ended than any private insurance formulary you will ever see. It is a leap of faith worth making.
What do you think? I’d be interested in hearing your prescription stories and thoughts.