Published in Orange County Register: March 21, 2014
Some California pharmacy benefit managers may be intentionally misleading doctors and making it more difficult for doctors do their jobs. As is often the case when health plans and benefit managers insert themselves into the physician-patient relationship, patients could ultimately pay the price.
Pharmacy benefit managers have sent misleading letters to California providers in both commercial and Medicare Part D in an effort to get them to switch patient treatments from brand to generic drugs or over-the-counter treatments. In their communications, the managers allege that doctors should switch because the alternative treatments are in some way superior and are the “preferred” agents for treating a specific patient type. However, in at least one case the claims have not been supported by the science.
Doctors I know aren’t swayed by such communications. I throw them away, myself. But doctors are also extraordinarily busy, inundated with emails, forms to fill out and forced to navigate costly bureaucratic hassles to even obtain simple treatments for their patients. If a doctor wasn’t reading the fine print, he or she might be misled into switching a treatment that shouldn’t be switched or feel pressured to make switch for fear of additional liability.
The pharmacy benefit managers’ claims have nothing to do with what is in the best interest of patients. They are sending misleading communications for one reason only – to drive up their profits on the backs of patients.
Doctors, including myself, choose a patient’s individualized medication strategy based on our years of experience and the specific needs of our patient. We know our patients, their conditions and the treatments that have worked. It is incumbent upon us to look after our patients and seek the best treatment regimen available to them. It is not in the best interest of our patient for doctors to allow benefit managers to change a medication based on their suggestions when they do not know the patient.
Fortunately for patients, California law empowers local officials to investigate and put a stop to this. In Section 790.03, the California Insurance Code prohibits “disseminating or causing to be made or disseminated before the public in this state … any statement containing any assertion, representation or statement with respect to the business of insurance … which is untrue, deceptive, or misleading, and which is known, or which by the exercise of reasonable care should be known, to be untrue, or misleading.”
To protect the safety and health of patients, California should investigate the efforts of pharmacy managers to mislead doctors. Decisions about how to treat patients should be made by physicians in consultation with their patients and based on the best clinical evidence available.
Marcy Zwelling-Aamot, M.D., is the vice chair of the American Academy of Private Physicians.