Requests for OTC prescriptions for a FSA burdens primary care

As reported by MSNBC, the federal government will no longer allow flexible spending accounts (FSAs) to be used for over the counter medications, without a prescription. FSAs, which are offered by many employers, allow you to use tax free dollars for medical expenses that aren’t covered by your insurance. FSAs are a great idea and can be used for things like eye glasses, dentistry, or even nicotine patches for smoking cessation.

The people most likely affected by this rule are those that take over the counter medications on a regular basis. Examples of such medications include pills for allergies, heartburn , aspirin for heart attack prevention, and smoking cessation aids. Medical supplies like insulin syringes and crutches, though sold over the counter, are exempted.

Now, you might think, “no big deal, I will just call my doctor and ask her to call in a prescription for a baby aspirin a day.” This would certainly solve your problem, but it adds to your physician’s problem and is a perfect example of the problems with the reimbursement system for health care, particularly for primary care.

If you are not aware by now, procedures get reimbursed much more than just talking to patients, which is why cardiologists make so much more than primary care physicians. However, anything that doesn’t happen in an office visit is generally not reimbursed at all. Primary care physicians can be great managers of your health care, done in a way that it convenient for you, and at a low cost — phone calls, emails, forms, etc. Problem is that the few minutes spent on you add up and take a whole lot of time. None of which is reimbursed by health care insurances under the current system. One doctor started adding these things up, and of the 50-60 hours each week the doctor put in, each day they:

  • Handled 23.7 phone calls
  • Answered 16.8 e-mails, mostly dealing with test result interpretations
  • Dealt with 19.5 lab reports, 11.1 imaging reports and 13.9 consult reports
  • Issued 12.1 prescription refills, excluding those issued during patient visits

None of these are reimbursed.

Now, here’s the real kicker about asking your doctor for an aspirin prescription. Not only are you compounding this problem, but you are also doing it not for better care (or any care for that matter), but so you can save money.

Finally, consider this.

Even though you can easily go to CVS and get aspirin on your own, if your doctor writes you a prescription for aspirin, legally speaking it is a whole different ball of wax. By writing a prescription, even if only for an aspirin, your doctor is rendering medical care. He is required by law to accurately document this. He is also liable for this care. If you had an adverse reaction to the aspirin prescribed, you could certainly sue.

Thus, by asking for a prescription for an aspirin, you are asking for the doctor to deliver care which he is liable for, which he will not get paid for, which (when added up for each patient) will take time away from true patient care and for the sole purpose of you saving yourself a few bucks.

Now, one of the reasons that primary care physicians have gotten into the mess that we are in is because we generally want to do what’s best for the patient and have been delivering this kind of free care for a long time. We actually were glad to do it, and only started complaining recently when what we got paid for actual care kept declining while our specialist colleagues kept getting more money, and our paper work started to increase. Many of us (probably including myself) will likely grant these requests without a complaint.

The point of this post was not to prevent your from requesting an OTC prescription from your physician for tax purposes. After all, the economy is still horrible and many patients truly need daily medications for allergies and heartburn that are quite expensive. The point is that are entire health care reimbursement system must change, and must change very soon. A few requests for OTC prescriptions for FSAs on top of perpetually threatening Medicare cuts might be all it takes for a primary care physician to stop practicing medicine altogether.

Matthew Mintz is an internal medicine physician and blogs at Dr. Mintz’ Blog.

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  • Pam

    Very good points about what is expected of our doctors. On the flip-side – as a patient, this new regulation is also costing me added tax dollars. I chose to discontinue my FSA account this year because the hassle of requesting prescriptions for every OTC drug was too cumbersome. I had bariatric surgery three years ago and the amount of vitamins and supplements I am required to take is more than normal and is required for my medical condition. But rather than go to the extra work needed to get prescriptions for every bottle of vitamins I need to buy – I decided to give my tax break back to Uncle Sam rather than waste what precious little free time I have (and that of my PCP’s). Thanks a lot Obamacare!

  • Doc99

    Here’s another issue that should be challenged in the courts.

    • pcp

      Nothing unconstitutional about this, unfortunately.

      I would rather challenge the primary care societies as to why they so vigorously lobbied for legislation that is so harmful to their members.

  • IVF-MD

    Great analysis!

    This prompts a bigger question. If a person works hard to earn money that is used to buy medicine for himself and his family, does he really need some slip of paper from a doctor in order to keep his money from being taken by force to profit some other person’s own projects?

    This is where the inefficiency of the system comes in. The patient has to waste time and energy trying to contact the doctor. The doctor and his staff have to waste time and energy documenting and generating the prescription. All this time and energy could have gone towards doing something useful. No value is created in the world by the wasted minutes of busywork when it could have otherwise gone to make life better for somebody else.

    • doc99

      “All this time and energy could have gone towards doing something useful. No value is created in the world by the wasted minutes of busywork when it could have otherwise gone to make life better for somebody else.”

      Yes, like writing phony excuse notes.

  • health blog

    This is a typical situation where a poorly thought out law is leading to predictable but presumably unintended consequences. Hopefully the law will be amended to just make OTC products not eligible for FSA reimbursement. We are being asked for a Rx for silly things, like body lotion, dandruff shampoo, nail clippers, …

  • Anna

    Can anyone explain the rationale by the change? My FSA VISA would not allow me to buy anything that was not in the database, so there could not have been a fraud issue (at least with our program) and they could demand our receipts if there was a question. Why doesn’t equipment require a script? I have yet to hear anyone adequately explain the “why” of this, and I have followed healthcare reform pretty closely.

  • a family doc

    We’re not taking on the liability of another prescription without a documented review of the problem and use of the medication.

    We’re not doing this review and discussion for free so given the difficulty in getting paid for phone calls these will be office visits.

    For many patients, their office visits are already busy with multiple chronic problems so this new issue usually will require a separate appointment.

  • AnnR

    So, with spring coming up and all thoses trees getting ready to reproduce, if I want a prescription for Sudafed I should make an appointment for some problem (allergic sympthoms perhaps?) and go in? I’ll still be asking for a prescription but in theory my PCP should get paid because I’ve shown up complaining of an ailment.

  • Smart Doc

    Pure intentionally malicious actions by the last Congress.

    Why should doctors trust or believe a single word from Washington?

    • Jeff Taylor

      Do you think your tax dollars should go towards OTC products for other people?

      By the way, no one should be taking drugs such as aspirin on a long-term basis without a physician’s advice. It says so on the packets.

      • IVF-MD

        That’s a dangerous backwards way of thinking, Jeff. The dollars those people are spending on their healthcare are THEIR dollars, not YOUR dollars. They worked to earn them, not you.

        • Jeff Taylor

          Well, I must have missed the tax break on FSAs somehow. Silly me. Or maybe you did. By the way, I’m about to buy a new smartphone for my own peace of mind – please afford me with a tax break, IVD. It’s for a good cause.

          • IVF-MD

            I would totally support your moral right to designate how the fruits of your labor are spent. In order to be happy and free, we have to first respect the rights of other people to be happy and free.

  • soloFP

    The best place to write “prescriptions” for OTC meds, work notes, FMLA forms etc will the office visit. If it needs to be documented, have the patient come if for an office visit. If you want to address lab results and phone call questions, have the patient come for them. I figured out that the specialist order Labs/MRIs at one office visit and then have the patient come in for resutls 2-3 weeks later for another office visit. If primary care docs would stop giving away so much free time/care throughout the date with paperwork and phone calls, then primary care docs could earn a decent wage and lower their liability.

  • jsmith

    Another brick in the Wall of Hassle. It’ll be interesting to find out what the med students think of all this. Match Day is March 17.

  • doc99

    Note to the AMA as well as Congress – Next Time Read the damned Bill.

  • A patient

    This change is really annoying me as a patient. When I made my 2011 benefit plan elections in November 2010, either the OTC prescription requirement change had not been publicized very much, or I managed to miss it (not difficult considering the amount of information we need to wade through when selecting our plan). So the $$ I elected to put in my FSA included the amount I expected to spend on OTC meds, as it had in 2010. Those pre-tax contributions come off the top of my paycheck. I expected to be able to use my FSA account to quickly and easily buy things like cold medicine, Advil, or baby Tylenol, when I needed them. Now, I don’t want to hassle my PCP to call in another prescription they won’t get paid for writing, and I don’t have the time to go in for another visit (or the money for it, since I pay for every non-preventive care visit with those same FSA funds!). So I’m paying for these items out of my limited paycheck instead. My budget is tight, so sometimes I’ve had to choose to pay the bills instead, and go without that expensive Nyquil that would have gotten me through a bad day with a cold – instead I’ve taken sick days and lost time in the office. And the FSA money is sitting there, unused by me…but I’m sure someone is benefiting from investing it! To me, this feels like a sneaky, underhanded change to the legislation, that isn’t benefiting patients or providers.

  • Easton

    As a family doc, this is another case of death by a thousand cuts. Each individual request isn’t that big of a deal, but I do have to document it. Even for Tylenol, I need to advise the patient to not exceed a certain amount, especially if they drink alcohol, or are taking other meds. Multiply this by 20 visits a day and it adds up.

    Since the first of the year, I tell patients they’ll need to come in for a visit for any forms or scripts. If they ask me for tylenol and TUMS scripts at a visit, I’ll happily do it. But if they call back next week asking for it, they’re going to have to come back.

    I try to direct all their anger at the government. I didn’t make this law. I think the government artificially created this barrier so that less people would use FSA and avoid taxes. Simple as that.

  • ninguem

    This was done, deliberately, by Congress and an Administration intent on doing anything they can to cripple consumer-directed healthcare. Cripple everything else, and you will be left with no choice except for single-payer.

    And single-payer is what Obama has wanted all along, he’s on the record as favoring a single-payer system.

    • Smart Doc


      Pure malicious calculated legislative malpractice, along with the thousands of other pages of the ObamaCare nightmare.

      Repeal and replace with honest reform.

  • Judy

    Perhaps we should put a lot of the blame for this problem on the drug companies. Many of drugs that used to be prescription-only are now over the counter. They cost a fortune and of course, insurance won’t pay for them anymore. There are drugs that would have cost me $20 for three months before that I pay more than twice that for one month now.

  • Finn

    Those of us who are self-employed and therefore have no FSA accounts are not feeling terribly sympathetic for those of you who do. I think soloFP is right: make us come in for prescriptions so you get paid for the work. I keep track of my prescriptions and refills so I don’t have to ask my doctor to call in a prescription outside of office visits. Even when I screw up (as I did recently, because I will run out 3 days before my next visit but need to buy mail-order so it will take 2 weeks), all I’m asking for is something that doctor has already prescribed and documented, so uncompensated time is minimized.

    • Doug

      Finn, we’re all proud of your diligence in managing your prescriptions. Gold Star!

      But why the hostility toward folks who put aside a chunk of their own pretax money for anticipated medical expenses? FSA plans have been very effective, and patients and doctors are both rightly frustrated with this poorly communicated, pointlessly punitive and petty new rule.

      I get that you don’t get to participate in an FSA. I was self-employed for a couple of years, and the tax writeoffs I received more than compensated things like an FSA. I paid the lowest percentage of my earnings in taxes those years by far.

      Everyone’s situation has pros and cons. You make all sorts of tradeoffs when you choose to be self-employed. Your snippy lecturing seems to be misdirected.

  • Leonard

    To top it all off the patients/customers have the inconvenient task of running to the doctor every we want to purchase something that should be available OTC. This is a no-common sense plan.

    I want to stop smoking, but I have to go to the doctor and pay a co-pay just to get a prescription for patches first. The main active ingredient in the patches is nicotine. Why do I need a prescription for patches, when I can buy cigarettes without one? Nicotine is in both, but the government would rather me die from smoking than provide me a product for quick and easy relief. This government is surrounding everything by red-tape. I’ve been covered under the FSA for 3 years now. They were okay before, no hassle for OTCs, but keeping up with receipts wasn’t any fun. Now it’s just way too much work. Maybe next year I’ll opt out.

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