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Lincoln Journal-Star: Pharmacists forced to serve insurers rather than patients
Local View by Steve Osenbaugh
Health care reform is on everyone's lips these days. What often goes unspoken, however, is the role that community - or independent - pharmacists play in the health care debate.
In Nebraska, 43 percent of the state's 354 licensed pharmacies, including mine, are independent. We strive to provide the best value and service possible to our customers - a goal that health insurance practices have made increasingly burdensome.
Over the past few years, it has become increasingly difficult for patients to obtain the medications their physicians prescribe. The pharmacy window is being turned into a battle zone as insurance companies impose barriers to filling the doctors intended medical order.
Patients are required to try and fail multiple treatment options before insurance will help cover the drugs that are FDA approved for their conditions. They also face formulary practices requiring a switch to drugs that are similar to-but not the therapeutic equivalent of - the prescriptions their doctors ordered. It's a practice designed to move them to generic therapies.
This is a dangerous trend because it forces patients to make decisions best left to physicians.
Not only do insurers benefit financially from these practices, so does a lesser known player in the health care industry - the pharmacy benefit management company. When a patient is switched from Product A to Product B, the insurer and PBM collect a rebate on product B.
Community pharmacists are caught in the middle of this tug of war between insurers and PBMs, physicians and patients. Typically, the only information we get from an insurer is a one-line statement that the drug has been denied.
The doctor is then brought into the process of finding an alternative therapy or trying to obtain prior authorization for the medication they originally prescribed. This takes hours upon hours. Physicians and pharmacists become unpaid employees of the insurance industry and are forced to take valuable time away from their patients. In fact, Health Affairs reports that physicians lose up to $30 billion each year in insurance-related administration costs.
Meanwhile, patients must choose between paying the full price for the medication their doctors prescribed or waiting until it or another drug is approved by the insurer. I have had customers simply walk away from the counter without needed medication.
Another restrictive practice is the use of higher co-pays to force the patient to an alternative medication. These switches not only lower the amount the insurer has to pay, but provide the PBM with additional rebate revenue.
Higher pharmacy co-pays also are used to channel patients to mail-order pharmacies - many of which are owned by PBMs - that offer lower co-pays. This detracts from the quality of care patients receive when prescriptions are filled at their community pharmacies.
When it comes to prescription medicines, the term co-pay is synonymous with "you pay." Because of high co-payments and/or coinsurance, patients pay at least 75 percent of the full cost of 32 percent of filled prescriptions in Nebraska, according to an independent Thomson Reuters 2007 study.
From a public health perspective, this is counterproductive because many drugs are prescribed to prevent more expensive and complicated conditions down the road.
We need to keep the insurance industry accountable to patients and their health care team. Patients should be allowed to receive the medications they are prescribed at reasonable co-pays. Insurers should be required to send a written communication requesting a prescription switch to both physician and patient explaining the medical indications and benefits of the proposed alternatives, the financial incentives in play, and advising patients of their right to consult with prescribing physicians before accepting revisions to their treatment plans.
I join with the American Medical Association and others in supporting a National Health Insurer Code of Conduct that would ensure patient access and safety by ending aggressive cost-cutting tactics that cause undue suffering to patients and interfere with the doctor-patient relationship.
Steve Osenbaugh is an independent retail pharmacist in Lincoln.
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All News Items
August 26, 2010 - The Lund Report: The Best Care Possible: You're Worth It
June 14, 2010 - American Medical News: 10 things health insurers must do to regain trust; The AMA, with endorsement from 68 state and medical specialty societies, outlines steps health plans must take to be credible in the eyes of physicians and patients.
February 27, 2010 - Providence Journal: The creepy third person in doctor’s exam room
November 28, 2009 - Newport News Daily Press: MDs under attack
November 04, 2009 - The Hill: A code of conduct for health insurers
October 27, 2009 - WCBU-FM 89.9 (Peoria, Ill.) radio news
October 26, 2009 - WEEK (NBC - Peoria, Ill.): Developing a doctor-patient relationship
October 12, 2009 - Las Vegas Business Press: Here's a prescription: A health insurers code of ethics
September 09, 2009 - Maryland State Medical Society Resolution 14-09
August 29, 2009 - The Island Packet: AMA code puts doctors, patients in charge of care
August 28, 2009 - Baltimore Times: Group calls on health insurers
August 27, 2009 - Baltimore Times: Nursing Maryland back to health
August 20, 2009 - Lincoln Journal-Star: Pharmacists forced to serve insurers rather than patients
August 19, 2009 - WSTM-NBC3: Prescription medication battle heats up in Central New York
August 17, 2009 - New York State Senator Jeffrey D. Klein blog: For Health or Profit? Klein Unveils Sickly Scorecard of Major HMOs
August 17, 2009 - New York Daily News: Prescription Prescription drug coverage marred by bureaucracy, survey says
August 13, 2009 - Leading African American Groups Call On Health Insurers to Dismiss Restrictive Practices
August 13, 2009 - San Diego Union-Tribune: Bureaucracy won't contain costs
August 01, 2009 - Huntington, W.V. Herald-Dispatch: Insurers put stress on the physician-patient relationship
July 21, 2009 - Chicago Tribune: They authorized back surgery but denied his $148,000 claim
July 17, 2009 - American Osteopathic Association calls for Development of Code of Conduct
July 12, 2009 - Houston Chronicle: Another kind of remedy for the sick; Code of conduct would protect patients
July 07, 2009 - Washington Post: Health Reform: Who Holds the Reins on Care?
July 06, 2009 - NATIONAL HEALTH INSURER CODE OF CONDUCT HITS 1000 SIGNATURES OF SUPPORT
June 30, 2009 - Atlanta Journal-Constitution: Code of conduct needed for health insurers, too
June 24, 2009 - Penn. Pharmacists Association: “A Patient Walks Up to the Counter …”
June 24, 2009 - Pittsburgh Post-Gazette: Broken bonds; The physician-patient relationship is being destroyed by the cost-driven decisions of health insurers
June 09, 2009 - Bellingham (Wash.) Herald: Time for a health insurance code of conduct
June 08, 2009 - Mississippi Business Journal: Transparency is the best medicine; Health Insurer Code of Conduct may improve the quality of care
June 03, 2009 - Frederick (Md.) News Post Op-Ed: Pharmacists pawns in health care's game of chess
June 01, 2009 - KUSI-TV interview with Dr. Jack Schim
May 25, 2009 - San Francisco Chronicle: Doctor pushes back against insurer scrutiny
May 08, 2009 - Fox News Health Blog: Bad Medicine: Is Your Insurance Company Hazardous to Your Health?
April 27, 2009 - Petition for Health Insurer Code of Conduct Garners Widespread National Support
April 20, 2009 - On-line petition launched in support of a national health insurer code of conduct
April 13, 2009 - Petition launched in support of a national health insurer code of conduct
April 09, 2009 - Westchester (N.Y.) Herald letters: Access to Quality Healthcare
April 01, 2009 - Los Angeles Society of Allergy, Asthma & Clinical Immunology Applauds the AMA for Developing Health Insurer Code of Conduct
March 24, 2009 - Arizona Republic: Patient care, not financial gain, must take priority
March 22, 2009 - Rochester (N.Y.) Democrat and Chronicle: Health insurers should agree to a code of conduct
March 20, 2009 - Buffalo News: Code of conduct would protect patients from insurers
March 10, 2009 - AfPA Launches Petition in Support of a National Health Insurer Code of Conduct
March 09, 2009 - Texas Medical Society: Health Insurance Code of Conduct Act of 2009; The Time Has Come
March 09, 2009 - American Medical News: MSSNY president: Insurer settlements highlight need for code of conduct
February 01, 2009 - Colorado Medicine: Health Insurer Code of Conduct?
January 24, 2009 - Fresno Bee: Doctors push code of conduct for insurers
December 10, 2008 - Lupus Agencies of New York State Applaud AMA's Resolution to Develop a "Code of Conduct" for Health Insurers
December 09, 2008 - New York State Rheumatology Society Position Paper: AMA Resolution 823
November 20, 2008 - National Minority Quality Forum Applauds AMA's Health Insurer Code of Conduct
November 14, 2008 - Alliance for Patient Access Applauds AMA's Health Insurer Code of Conduct
November 13, 2008 - Alliance for Better Medicine Calls on California Health Insurers to Adopt a "Code of Conduct"
November 13, 2008 - Los Angeles County Medical Association Reinforces AMA's Call for a Health Insurer Code of Conduct
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