Who’s really prescribing medicine? Hint: It’s not doctors.

In our current health care system, doctors should get to decide what medication is prescribed. Typically, the patient and doctor decide what is the best, then the prescription gets sent off to the pharmacy. When the patient goes to pick up the prescription, often they find a different one instead or are told that their health insurance coverage is not covering that prescription. Instead of receiving the best medication for themselves, they are often told to just take this medicine instead. Formularies have gone mad and not in a good way.

Insurance companies will tell you that they send copies to physicians and patients on an annual basis, However, those formularies change and those lists are not always kept up-to-date. Even when we chose a medication that may be listed on a formulary, there is no guarantee that it will actually be covered when a patient goes to the pharmacy. The pharmacist then usually calls to ask to change to a different medication based on the patient’s insurance coverage. I know many people get mad at the pharmacist, but this is not his/her fault — it is entirely on the insurance plan. And patients sometimes get angry with me as well but I do not possess a magic wand that will make the insurance company pay for whatever medication we wish.

Many times, the decisions to change to a different medication can be harmful to patients or just make no clinical sense. And it is not supposed to — it is all about cost. Insurance companies cover the cheapest medications possible and ones that pharmaceutical companies lobbied to have covered. So many times, I have seen a patient controlled on medications they have been taking for many years develop an exacerbation of their disease because they were forced to take another medication instead. There are few exemptions for patients with chronic disease who are doing well on their medications. Believe me, I have tried and begged to no avail. It makes no difference to most.

And it is not always the same class of medication an insurance company tries to substitute. A patient’s blood pressure was quite elevated and I prescribed an ARB (angiotensin receptor blocker) to lower it. Based on all clinical knowledge of my patient, I felt this was the most effective and safest choice for this particular patient. However, when the prescription was sent to the pharmacy the technician from the pharmacy called back and said the patient would need to take a beta-blocker instead. When that change was requested, they didn’t realize that the patient’s heart rate was already low and that adding this medication may slow it to the point the patient would require a pacemaker. As previously stated, these decisions are made solely based on cost considerations and not sound medicine. Yet, this is what happens every day in most medical practices in the U.S.

While no one can argue that health care spending in our country has gotten out of hand, we need to curb those costs in the right fashion. Putting patients in danger to cut costs is not the answer. Insurance company representatives who never received any medical training should never make medical decisions. It is time to end this formulary madness.

Linda Girgis is a family physician who blogs at Dr. Linda.

Image credit: Shutterstock.com

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