How should pharmacy benefit managers (PBMs) and pharmacies communicate with physicians?

by George Van Antwerp

In the pharmacy and pharmacy benefit manager (PBM) business, there are lots of reasons to reach out to a physician:

* Drug-drug interactions
* A chemically equivalent version of the drug prescribed is available
* A therapeutically equivalent version of the drug prescribed is available
* The prescribed drug is not covered
* A prior authorization is required
* The patient is required to try an alternative drug first (step therapy)
* The prescribed drug costs too much and the patient would like a new drug
* The prescribed drug had unplanned side effects
* The patient’s prescription has to be renewed
* The patient is required to move to mail

The question is always how to best do this.

Here are some options:

1. Call the physician’s office.
a) Using call center agents would be expensive, and after navigating an interactive voice response (IVR) tree and talking to the front office staff, they would simply leave a message. This would just lead to an ineffective back-and-forth in many cases.
b) Automated technology won’t effectively navigate the IVR tree, sit on hold, and deliver a message.

2. Send a letter to the physician.
a) This allows for the proper level of information to be provided so the physician has time to look up the patient record and respond.
b) For most of the cases above, the time lag on this would be unacceptable.

3. Fax the physician.
a) This is the default solution since you can deliver mail type content in a timely fashion.
b) But, there is no great physician fax database.
c) And, do physician’s read the faxes?

4. E-mail the physician.
a) This isn’t really an option since there’s no physician e-mail database (that I know of) and you can’t send PHI via e-mail.
b) Your only option here would be to send e-mails that alerted the physician to log into a portal where all these messages were waiting for them.

5. Use the EMR or eRx application.
a) As physician’s get more automated and technology becomes the default workflow solution, everyone sees this as the holy grail. A pop-up can tell the physician about inbound messages for them to respond to.
b) Some solutions hope to push this messaging to the time the prescription is written which I think is fascinating, but I don’t imagine a physician wants to deal with all that during the patient encounter. (Maybe I’m wrong.)

So, what I’m interested in hearing from physicians on is what works. I’m sure you want to say that most of these messages aren’t things you want to deal with, but plan design is here to stay and works to control costs. I’m sure some of you feel this is the “managed care system” telling you how to prescribe, but we know that the amount of information needed to keep current on everything is overwhelming. And, cost matters to patients which means getting them on the right drug that they can afford will impact adherence and ultimately outcomes.

How should PBMs and pharmacies communicate with physicians?

George Van Antwerp is the general manager of the pharmacy practice at Silverlink Communications who blogs at Enabling Healthy Decisions.

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  • Edward Pullen MD

    Really we all just wish you did not exist. I get several of these a day, I think essentially all by fax. I read them just because it is important to my patients that they get their meds. The majority are related to saving money for the plan, the patient or both. These are fairly easy to respond to. The ones that cause pain are the ones asking many questions to qualify a patient for the drug. It takes far too much time to answer 8-10 specific questions about why a patient is on a Proton Pump inhibitor for GERD, or why a COX 2 drug has been prescribed. (In my experience if I answer all the questions, the drug is always approved) It seems like the goal is to make the process so cumbersome the plan can blame the doctor for not providing the med, avoiding saying we need to save money.

  • family practitioner

    I agree with Edward Pullen.
    The role of these pharmacy management plans is classic triangulation, pitting doctors against patients, all in the name of saving the insurance company money.

    Quite frankly, it clogs up my office with paperwork and frustrates patients, who invariably blame the doctor for this inefficiency. Many times the patients are even told by the pharmacists that “we cannot give you that drug because your doctor did not give us the correct information.” Translation: it is your doctors fault.

    Quite frankly, I do not really care which statin or ppi my patient takes; let them argue it with their insurance plan.

  • George Van Antwerp

    Thanks for the comments. I’ll try to keep monitoring and dialoging on this topic.

    First, on prior auths (Edward), I completely agree. In general, the majority (>90% in my experience) are approved. The question of course is whether the sentinel effect has value for those that may over use certain medications. I have been trying to work with several clients to push for an automated prior auth process which would be easier for physicians (or your staff) to use.

    Second (family practitioner), I think there are a few ways to help with this, but of course, I don’t make the rules. I’ve seen physicians that write scripts that just say “Pick Lipitor, Zocor, Crestor, etc. based on what’s lowest cost or on formulary”. I don’t know if it’s legal, but it gets to your point that you just want the patient taking a statin, ppi, ssri, etc. I’ve also talked before about the value of having pharmacists pick the drug based on drug-drug interactions, copay rules, and talking the patient. That way the physician can diagnosis and prescribe a category of drugs.

    BTW – I’m going to stay out of the argument about the value PBMs add for now. But, since they’re going to be around and I’m a consultant to them, I’m just trying to figure out how to make this process easier and in line with physician workflow and needs.

  • stargirl65

    I refuse to fill out any paperwork for free. If I get a prior auth then the patient has to come in while I fill it out to make sure I get the information correct. If it is on the phone they get to sit by the phone and have me listen to the ridiculous amounts of prompts followed by getting cut off, redirected, etc. They have been told by the pharmacy “it is a simple phone call” and are surprised at the time (often 15 minutes or more) it takes to even get to a live person. The entire time I am doing this the patient’s insurance is getting charged by the minute as the patient is right there face-to-face. If the patient has a deductible then they are paying. They are starting to get annoyed as well by these.

    I always try to utilize the least costly, appropriate medicine available. Sometimes the patients have failed these medicines or have contraindications to the medicines. Then I need to use something more expensive. I resent the fact that I have to ask “permission” to use the appropriate medicine. Especially when the company has access to the medicines and can see I just prescribed the cheaper alternatives for the step therapy last month( ie ACE before ARB). Don’t they even look? Why should I have to? I am not the one requesting the change.

    It is impossible to keep up with the ever changing formularies for companies. I once had a patient start on nexium, a year later they made me switch to aciphex, a year later to protonix, then a year later back to nexium. I work with innumerable plans, how am I to keep track of all this?

    The only way for this to be easy for everyone is to automate it, but that cost should be borne by the insurer since they are the one mandating the changes and garnering the savings. (The only reason for PBMs is to save money for the insurance company and make life miserable for doctors.)

  • Primary Care Internist

    much like mandated EMRs – benefit to medicare & private insurers, but costs to be borne by the doctor.

    I agree with Stargirl65 – the only way to make it work is to have the patient sit there with you, so they are directly involved in your loss of time seeing other patients, and understand that your time costs money.

    If all of us start doing this, then patients will slowly get the message that the problem is with their insurer, and it’s PBM, rather than their doctor.

    Really, what the hell do i care if the patient is on protonix, omeprazole, or nexium? and i REALLY don’t care to know that aetna’s formulary PPI is protonix, but blue-cross’ is aciphex!

  • Primary Care Internist

    also, this approach will dispell the myth that doctors are somehow paid or incentivized to write for one drug over another, a myth perpetuated by our greedy hypocritical politicians:

  • George Van Antwerp

    Primary Care Internist – Thanks for your comments.

    First, I agree that politicians are out of the loop and use small pieces of often biased or outdated information to push a point.

    Second, isn’t there a value to getting patients on the lowest cost prescription which should improve their likelihood to stay adherent?

    All – Has electronic prescribing impacted any of this or could it by showing you the drugs on formulary before you write them and pushing potential edits to the point-of-prescribing so that you avoid the follow-up after the fact?

  • stargirl65

    The cheapest drug available is NOT always the cheapest drug on a certain plan. Many PBMs make deals to get a certain drug cheaper than others. Also the prices of drugs like Nexium, Aciphex etc are all similar. It is simply which one the PBM prefers due to preferential contracting with their suppliers. This changes yearly for the same company.

    Also many patients have simply failed the cheaper drug for one reason or another.

    Electronic prescribing is part of the answer. Having access to the information at the time you write the prescription would be very helpful. This service is available for some insurance plans with your EMR. The catch is that it is NOT free. There is a monthly access fee. In addition you have to pay an IT person to set up the VPN tunnel with the service. Why should I be paying for this access when it truly is not my concern which PPI is the drug of the month?

    Also a patient may be placed on a certain drug preferred by a plan, but then the plan changes the preferred drug. Now you might have to switch even though the patient is doing well on the drug they previously preferred. Sometimes the switch can be no problem, but there are problems enough of the time to make is risky. Also when making a change, you need to bring the patient back an extra time to see if the new drug is working OK. This is an extra visit the patient does not want.

    Also some of the patients do not fit the preferred drug due to ineffectiveness, allergic reaction, medical contraindication, other drug interaction, etc. The real time adjudicating simply says if a drug is “permitted”, it does not let you say why you want the nonpreferred one over the preferred drug. You stil have to fill out forms. Also some classes of drugs require the authorization for ALL drugs in the class. These can be simple (did you try an ACE before ARB?) to very complicated (did you try this, get this blood work, enter results here, last visit, other things tried, etc).

  • R Watkins

    PBMs exist to maximize profits for themselves and insurance companies, not to lower overall healthcare costs. One way they do this is by treating physicians and their staffs as free labor. They contribute nothing of benefit to the system.

  • stargirl65

    Today a patient came in. She mailed her rx and her money to her PBM. The pills did not come and she was out. She called the PBM. They stated they were OUT OF her medicine and it was on backorder. She had to get an emergency prescription from the local pharmacy but there a one month supply costs the same as a 3 months supply mail away. She waits a few weeks. No phone call from PBM and no pills. She calls again. The medicine is on backorder BUT they can fill it with brand name. The catch, she needs to get a new rx from her doctor stating “brand necessary” and mail the new rx to the PBM. So she came in today to get a new rx that says “brand necessary”. But why is it necessary? Only because THEY cannot get generic. This is ridiculous.

    WHO IS THIS HELPING AND HOW IS ALL THIS SAVING ANYONE (BUT THE INSURANCE AND PBM) MONEY? They took her money and won’t provide the service? They want he to go without medicine? They make her get a new rx when the old one is fine?

  • R Watkins

    Mr. Van Antwerp:

    I actually found that e-prescribing made things worse, not better: it forced me to spend time in the exam room jumping through all the pre-auth hoops (“Is the patient’s ED psychogenic? Is it related to other medicines” and on and on).

    I’d rather risk sending in a non-authorized script and let my highly trained staff clean up the mess later. The best use of my time is taking care of patients.

    The expense and time that doc use up dealing with PMBs is a not-insignificant factor in the deterioration of health care in this country. PMBs only take from the system; they give nothing back.

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