Why Did I Get the Wrong Rx?

A recent memo from Centers for Medicare and Medicaid Services (CMS) clarifies why many Americans aren’t getting the medications they need. The wrong person is choosing your prescription drug, and it isn’t your doctor.

According to CMS, starting in 2020, Medicare Part D health plans can implement “indication-based drug therapy.” Medically, an indication is pain in a joint (arthritis) or pneumonia (infection in the lungs). Doctors do not treat indications; we treat patients, one at a time, each with his or her own name, unique medical history, and individual reactions to specific medications, whether good or bad.

Consider Mrs. Jane Doe who has with joint pain from arthritis. A Medicare health plan might approve Ibuprofen as the first-line drug for the indication: arthritic pain. This drug works in many people, has minor side effects and is cheap. Unfortunately, Ibuprofen doesn’t work in Mrs. Jane Doe, and her doctor knows it. Nonetheless, Mrs. Doe gets Ibuprofen — the wrong drug for her — because that is what a bureaucrat, not her doctor, has decided,

In other words, the person choosing your medications has no medical training, no license to practice medicine, and does not even know your name.

Prescribing the wrong R_x for you occurs throughout health care. It is not limited to Medicare.

Most health plans require doctors in their panels to use the “fail first” approach, also known as step therapy. When starting treatment, the treating physician can only prescribe the most “cost-effective, medically sound” medication. “Cost-effective” means cheapest drug for the health plan. “Medically sound” means lowest risk of side effects, which often means least likely to be medically effective. After the first drug fails to help the patient, the doctor is then allowed to take the next step with a second drug also chosen by the health plan. Eventually, when all the cheap alternatives fail, the doctor may be allowed to special order the right drug. The bottom line? An insurance actuary, not your doctor, choses your R_x.

Doctors no longer take a small white pad out of a lab coat pocket to hand-write a prescription. Instead, today they order medications electronically through pharmacy benefits managers. A pharmacy benefit manager will list what drugs are allowed. If the one you need is listed, great; if not, too bad. In this case, a computer program — not your doctor — decides what medication you get.

Whether it is a faceless insurance actuary, an anonymous government bureaucrat, or a soulless prescription benefit manager program deciding what medication you get, the prescriber does not know you or your medical history and does not care. The primary concern is to “to reduce the cost of drugs” for the bottom line, not for you, the patient.

So why did you get the wrong R_x? The answer is simple: Neither you nor your doctor is in charge. The federal bureaucracy and insurance companies are. And when you wonder why the cost of drugs is out of reach, look no further than 1717 Pennsylvania Avenue in Washington, home of the Food and Drug Administration (FDA). This massive federal agency protects monopolies such as Mylan’s with its EpiPen, suppresses market forces and adds $1 billion to $2.6 billion to the prices we must pay for our meds.

The solution is also simple, albeit politically unlikely: Stop Washington’s insurance mandates and FDA instructions from deciding what medications you receive.

It’s time to return decision-making authority to those to whom it rightfully belongs: you and your doctor.