Woes at the Pharmacy

The Public is Unaware of the Problems that Plague Filling a Prescription

This commentary was suggested to us by Critica advisor Carrie Corboy. Carrie is a pharmacist and Senior Director at Janssen Research and Development, a division of Johnson and Johnson. She focuses on medication adherence, policy, and development and helped us prepare this commentary.

         Once upon a time getting a prescription medication was fairly easy. Your doctor or other qualified healthcare provider wrote you a prescription on a prescription pad, you took it to your local pharmacy, and later picked up your medication. Your pharmacist was usually relaxed and had time to answer questions you might have about how to take the medication and any adverse side effects. Maybe it never really was that easy; it certainly isn’t today.

         We have written before about the problems we have getting facts about our healthcare system in order to make rational decisions to reform it. Here, we address four areas that concern getting medication from a pharmacy: electronic prescribing, prior approval, overworked pharmacists, and prescription benefit managers.

Electronic Prescribing is Mostly a Benefit

         Doctors in most cases no longer “write” prescriptions on those little prescription pads but send them directly to the pharmacy via an electronic prescribing system. Electronic prescribing, or e-prescribing, has many advantages over written prescription. Foremost among them is increased safety: pharmacists no longer have to try to interpret physicians’ illegible handwriting, which cuts down on errors. E-prescribing also reduces the number of phone calls needed between pharmacist and prescriber, thus saving valuable professional time, and allows for efficient recording of each patient’s medication history (although this may only apply to the pharmacy chain where a prescription is filled).It also reduces the problem of stolen prescription pads and forged prescriptions.

Electronic prescribing has many advantages over written prescriptions, although there are still a few problems (image: Shutterstock). 

         But there are also problems with e-prescribing. Prescribers may feel that the available fields on the e-prescribing page do not adequately convey exactly what they want their patients to take and how it is to be taken. To overcome this, the prescriber can write comments in a notes section, but these not infrequently contradict the instructions in the drop-down menu field. Resolving the problem takes up pharmacist time. Electronic prescribing also makes it easy for chain pharmacies to message doctors repeatedly to refill prescriptions; sometimes this is helpful but, as we have been told, other times it involves medications the doctor and patient have decided to discontinue, and the repeated reminders clog up the physician’s inbox and degrade the physician-pharmacist relationship. 

Another problem we have heard is that e-prescribing makes it easier for doctors to refill prescriptions multiple times without seeing the patient in person; it is generally recommended that patients be reevaluated at some reasonable intervals while taking medications for prolonged periods of time. Finally, electronic prescribing software can stop working because of problems with the e-prescriber vendor’s computer system; doctors and patients must wait while those computer problems get fixed.

         Overall, the benefits of e-prescribing seem to clearly outweigh the downsides and we certainly do not advocate a return to written prescriptions. But now that big businesses have taken over the entire prescribing industry, including e-prescribing vendors and chain pharmacies, there is clearly the need for a number of improvements, some of which may have to be legislated.

The Bane of Prior Authorization

         A more pressing problem arises when that prescription hits the pharmacy and a red flag goes up: your insurance company won’t cover the medication unless the doctor who prescribed it gets in touch with the insurer and justifies the prescription. This process is called “prior authorization” (also known as prior approval and pre-certification).  Perhaps it was once a good idea. For example, insurance companies are absolutely right to balk at paying for a brand name medication when a cheaper generic version is available. Asking the doctor to justify why he thinks a brand name drug is necessary is reasonable under those circumstances. In fact, some states have laws that require the dispensing of the equivalent generic product, when one is available,  unless the doctor specifies on the prescription “dispense as written” or “brand medically necessary” or the patient demands the brand name medicine. 

         But the prior authorization procedure has clearly gotten out of hand. Although health insurance companies claim it is a method to improve patient outcomes by ensuring that only safe and necessary medications are prescribed, physicians believe that prior authorization is merely a tool health insurers use to lower their costs. There has been a steady increase in prior authorization requests, placing an ever-increasing burden on physicians to spend lengthy amounts of time on the phone with insurance company employees. A survey by the American Medical Association (AMA) found that medical practices spend an average of two business days per physician on prior authorization requests.

Prior authorization requests are associated with delaying care and harming patients. Prescribers are also frustrated, according to the AMA survey, because many of the drugs for which prior authorization is required are “neither new nor costly.” One physician we know, for example, was asked to do a prior authorization for an antidepressant that has been available as a cheap generic for decades. She was given a list of medications she must give the patient first before the requested antidepressant; none of the drugs on the list were antidepressants and some were drugs for cancer and hypertension.

As another example, let’s take someone suffering with depression for whom a psychiatrist has prescribed the antidepressant bupropion. One insurer may cover the cost of generic bupropion, another might insist that only the brand name drug, Wellbutrin, will be covered, while a third may insist that a totally different antidepressant be tried first. Since there is little evidence that there is much difference among antidepressants in terms of their effectiveness and that what might be more important in antidepressant selection is the patient’s other circumstances (other diseases and medications that might make one antidepressant better than another), this prior authorization is unlikely to have anything to do with what is best for the patient. Nor is it clear that it is related to cost, since three different insurers seem to have a different price for the same drug.  

Worst of all, neither prescriber or patient in this case can predict which version applies to the patient’s own specific insurer, something that will likely not be revealed until either the physician gets a note on her electronic prescribing application that prior authorization is needed or when the patient shows up at the pharmacy and is told the medication cannot be filled. This process clearly needs increased transparency and possible regulatory relief. It should only be used when there is a legitimate potential for improving patient care or lowering costs without harming care. Right now, it seems a tool perversely designed to harass healthcare professionals and subject patients to needless delays for their medicines.

The Pharmacists’ Plight

         Let’s say your doctor has successfully e-prescribed your medication and succeeded in a prior authorization process to get your insurer to cover its cost (minus co-pays, co-insurance, or what’s remaining of your deductible, of course). If you’ve decided not to have your prescription delivered to your home, you are now ready to go to the drugstore to pick it up. Your local pharmacy is likely to be part of a huge national chain, like CVS, Rite-Aid, and Walgreens.[1] As you approach the pharmacy of the larger retail store you likely can hear things like “one pharmacy call” repeating over and over and the phone ringing and you can see the car waiting at the drive up window. Behind the pharmacy counter you will still find someone who has undergone rigorous training to become a pharmacist—in fact, they hold a doctorate in pharmacy– and an expert on the risks and benefits of a wide range of drugs. But that pharmacist is also working under tremendous corporate pressure. 

According to a recent New York Times report pharmacists said “they struggled to keep up with an increasing number of tasks—filling prescriptions, giving flu shots, answering phones and tending the drive-through, to name a few—while racing to meet corporate performance metrics they characterized as excessive and unsafe.” These corporate metrics, like answering the phone within three rings, are generally  unrelated to patient care quality and create an environment of constant multitasking and interruption. This has led to concerns that pharmacists will make more errors filling prescriptions. Writing on behalf of the Pharmacist Moms Group, pharmacist Suzanne Soliman asked that:

..chain pharmacies to publish all of their metrics for calculating pharmacist and technician hours and ultimately error rates. We also encourage pharmacies to publish how many prescriptions are filled each month and how much staff they have so that patients can make an informed decision as to which pharmacies provide adequate staffing to suit their needs.

Pharmacists are highly trained health professionals, but because they now work for large chain pharmacies the demands on them have become severe (image: Shutterstock). 

         In addition to causing practical problems like increasing the prescription fill error rate and taking up valuable pharmacists’ time, corporate demands on pharmacists pose a moral dilemma for them. A recent ethical analysis of pharmacy practice argues that pharmacists work under ethically challenging circumstances, provoking a “moral crisis” in addition to the practical one. We believe that the former is as important as the latter in causing pharmacist distress. 

American corporations are, of course, permitted to keep their corporate secrets. We don’t require that General Motors tell the public what new car designs they are working on or department stores to reveal their number of employees. But if overworked pharmacists are in jeopardy of making errors and becoming burnt out, it becomes a public health issue that the public is entitled to fully understand. Soliman’s plea for more transparency from the chain pharmacies seems urgently needed both to protect the health and safety of pharmacists and of their patients. We may not be able to return all the way to the days of the friendly neighborhood pharmacy, but we have a right to demand that pharmacists have working conditions that do not jeopardize our safety.

PBMs Rule

         At this point, you hopefully have a bottle of the medication your doctor wants you to have in hand and you may even have been able to ask the pharmacist to clarify the instructions on the bottle and explain the drug’s adverse side effects to you. It is now time to pay for the medication, and you hold your breath wondering how much it will be. You’ve been taking this medicine for a long time and you know it is a generic version, but its price seems to change from month to month and from pharmacy to pharmacy. You wish that you could just look up the price of 30 pills of this medicine on the internet. It’s not like buying a car, after all. Shouldn’t somebody be able to just tell you how much it costs?

         In fact, how much drugs cost in the U.S. is a mystery to most of us and a large part of that stems from something called pharmacy benefit managers (PBMs). You may not have known that you have your very own PBM. If someone is covering the cost of your prescription medication, you probably do have a PBM. It is not there to help you get your medication. Rather, a PBM is a corporation that serves as a middle person between insurers and other prescription medication payers on the one hand and drug companies on the other. The insurers essentially hire a PBM to manage the pharmacy benefit portion of your health insurance or Medicare Part D plan. The less the PBM actually spends buying drugs from drug companies, the more money they get to keep. More than 90% of the $450 billion we spend annually on medication is processed by PBMs.

         PBMs are supposed to lower the cost of drugs by using their purchasing power to negotiate better prices from drug companies and by keeping lists called formularies of medications they will cover. Putting only the cheapest versions of drugs on the formulary is another way that PBMs try to hold down costs.  Ideally, these savings would be passed on to consumers.

         But PBMs operate largely in secret and it increasingly turns out that they are maximizing their own profits but not necessarily saving consumers money. One suspect PBM practice is to receive so-called rebates from drug companies. Rebates are funds returned by drug manufacturers to PBMs to make it more attractive for the PBM to list the drug company’s more expensive drugs on their formularies. The PBM shares a portion of the rebate with the health insurer and retains the rest. Ideally, this would create an incentive for the insurer to lower premiums, but it also creates a clear incentive for PBMs to put high cost drugs on the formularies and this translates into higher costs for patients. Interestingly, until very recently, pharmacists were forbidden from telling their patients that they could pay less for a prescription by paying for it outside of their insurance coverage. 

Rebates are big business: the amount of money rebated by pharmaceutical companies to PBMs increased from $39.7 billion in 2012 to $89.5 billion in 2016. The amount of rebate for each drug, however, is usually a corporate secret and can change annually as PBMs negotiate new prices with manufacturers. This means that consumers and the employers providing health insurance are largely kept in the dark about how much a drug actually costs and often cannot find out what they will pay until they are at the pharmacy counter with a credit card in hand.

Last, and possibly worst, the prices of medicines that are made available to the public—called average wholesale price or list price–are quite high  because they are the starting point to which the rebates are applied.  However, for people with no medication insurance, this is exactly the price that they pay for medicines.  Therefore, the most vulnerable people are charged the most.  It thus becomes clear why many patients simply do not fill the prescriptions that they need to survive–they cannot afford them..

         Physician Guy Culpepper wrote on LinkedIn recently that CVS Caremark, the PBM of the CVS Health corporation, was “only covering the Brand name version of some prescription drugs. So if I prescribe the generic, in an effort to save my patient money, CVS Caremark will refuse to cover it.” Even though the real price of the generic drug is less than its equivalent brand name version, in this case the PBM gets a bigger rebate for covering only the brand name version. That rebate, however, is not always passed onto the customer but instead can result in a higher price and more out-of-pocket cost. Culpepper called rebates “kickbacks” and went on to state that “PBMs will pretend these ‘rebates’ will mean lower costs for the payers. But if that were true, PBMs would support transparency to show us just how much money they save us.”

         If rebates save money, that is of course not obvious to consumers, who face ever-increasing prices for medications and higher out-pocket-costs. An analysis of the effects of rebates on the cost of drugs for seniors covered by Medicare Part D showed that they increased both out-of-pocket costs and Medicare drug spending. Once again, the place to start fixing this problem is with greater transparency. Regulators should demand that rebates be publicly disclosed, if not eliminated altogether. Corporate secrets do not seem justified in managing our very expensive healthcare system. We desperately need to reduce healthcare costs so we can extend quality coverage to more people. Rebates turn out to be a very poor method of controlling drug costs and more likely to improve corporate profits instead.

         As we have noted before, Americans spend much more for healthcare than citizens of other high-income countries and get the poorest outcomes in terms of lifespan. Medication spending is one factor that is increasing our exorbitant healthcare cost outlay and several of the elements we have discussed here also have the potential for jeopardizing patient well-being. Our concerns about electronic prescribing do not undermine its many benefits, but prior authorization, overworked pharmacists, and rebates to prescription benefit managers are all detrimental in their present form to the public’s health, create dissatisfied healthcare professionals, and function poorly to control costs. 

In all of these cases, the minimum step to improvement would appear to be legislating increased transparency. We need to know how insurers and their PBMs determine what prescriptions require prior authorization and reform that process so it truly saves money without tying up doctors with endless phone calls and delaying treatment; we need chain pharmacies to publish their work flow metrics and make it clear that driving pharmacists to the point where mistakes are unavoidable is unacceptable; and we need drug companies and PBMs to reveal the complex tangle of drug rebates and, if necessary, regulate this process so that it truly serves to reduce costs instead of forcing people to accept more expensive drugs and higher out-of-pocket costs. Making medication unaffordable to some people is obviously not in the service of improving healthcare.

         A person who needs to fill a medication prescription is likely suffering from a medical problem that is at very least distressing and uncomfortable and at worst painful and even life-threatening. Getting the prescription filled should not add to the patient’s woes, nor should it drive healthcare professionals to distraction or unnecessarily drive up healthcare costs. It is time we examine carefully the whole system by which we get our medication and intervene when necessary at every step of this complex and often mystifying process.

[1] Disclosure, a Critica team member, Jack Gorman, owns a small amount of stock in the Rite Aid Corporation.

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