An 86-year-old woman began experiencing nausea and weakness after her health insurer had her change from a blood pressure medication she had long used to one it preferred.
A 63-year-old woman developed severe muscle pain and arthritis after her high cholesterol medication was changed.
Both felt the consequences of a growing medical trend in which pharmaceutical manufacturers boost their profits by pressuring doctors to change the drugs they prescribe, sometimes to the detriment of their patients’ health.
A report detailing the problem was released in Washington on Wednesday by New York City Public Advocate Mark Green and the Consumer Federation of America.
The consumer groups said drug companies spend billions of dollars acquiring pharmaceutical benefit management companies, or PBMs, in trying to control which prescription drug services health insurance plans provide.
“It’s the best-kept secret in health care,” said Howard Metzenbaum, a former senator from Ohio and chairman of the Consumer Federation of America. “Drug companies have taken control over the kind of prescription drugs that patients can obtain in our medical system.”
Some of the nation’s largest drug companies, including Merck, SmithKline and Eli Lilly, have bought PBMs, the consumer federation said.
PBMs draw up lists of drugs, called formularies, that dictate the prescription medications insurance companies and managed-care organizations will pay for. The price of a drug and its therapeutic value are considered by a PBM when it creates a formulary.
Doctors are encouraged to prescribe and druggists are instructed to provide only drugs included on a formulary. If the drug is not listed, a physician can file an appeal, which doctors say can take weeks, or the patient must pay out-of-pocket for the drug.
More and more physicians and pharmacists are being pressured to change prescriptions because doctor-recommended medications aren’t on the approved drug lists of the health insurers.
“People don’t really know what happens when they take their prescription to be filled,” said Metzenbaum. “Often there is an attempt to switch the drugs that the doctor ordered.”
If the pharmacist can’t switch the prescribed drug to an equivalent-approved drug, then the patient is often faced with paying the full cost of the prescription. So, drug switching can save patients money. But drugs and patients are different, and doctors prescribe specific drugs for reasons.
“Not all patients respond the same to the same medication,” said Dr. Bob Reardon, chairman of the American Medical Association’s board of trustees.
“The PBMs are determining for the American people what drugs they are going to be able to take for their needs,” Metzenbaum said. “This insidious development has occurred in the American medical system.”
Tobey Dichter, a spokeswoman for Diversified Pharmaceutical Services, a subsidiary of SmithKline Beechum that helps health insurers develop lists of drugs approved for insurance payment, says that work is done with the patients’ best interests in mind.
She says insurers have discretion to pay for any drug a patient may need. How much various drugs may cost the patient depends on the plan the patient chooses.
“At no time would Diversified authorize a switch without prior physician authorization,” she said. “Diversified works with physicians to help patients get the therapy that works for them and reduces their costs.”
Lilly, which owns PCS Health Systems, a PBM, said its program is “completely voluntary.”
“Physicians always make the final decision about what prescriptions their patients receive,” the drug maker said in a statement.
Green, the New York City public advocate, remains unconvinced.
“Millions of patients are not getting literally what the doctor ordered,” he said. “And they’re unaware of it because of a network of gag rules, of fears of reprisals, of conflicts of interests.”
Physicians and pharmacists have expressed concern about the practice, but they are afraid to speak out or fight the switching practices for fear of being blacklisted by the health insurance plans or being dropped from the plan, said the report’s authors.
“What should be a professional medical decision made by a doctor and patient has now become a business decision that may have as its bottom line the deterioration of the patient’s health,” said Green.
Green said that over the past three years drug companies have spent $13 billion to purchase the three largest PBMs. More than half the American public is enrolled in prescription drug plans administered by PBMs, and that number is expected to increase, the consumer groups said.
The Consumer Federation of America is proposing legislation that would give the Food and Drug Administration more power to regulate pharmaceutical promotional practices. Its proposal also would increase consumers’ ability to obtain nonformulary medications when prescribed, give the Federal Trade Commission power to investigate the merger of a drug company and a major pharmaceutical benefit manager, as well as investigate drug switching.
“The question is not whether, but when government and business will respond and put patients first,” Green said.
xxxx BAD MEDICINE In a survey of about 250 New York physicians, 83 percent said they had been contacted by health plans or pharmacists to change prescriptions, 76 percent believed that a health plan’s substitution diminished the quality of care, and 57 percent said their patients had problems after switches.