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Pharmacy Benefit Managers vs Physicians: Let the Games Begin!

Posted Jul 24 2011 6:00am
As a gastroenterologist, I treat hundreds of patients with heartburn. You already know the names of the medicines I prescribe, since they are advertised day and night on television and appear regularly in print newspapers. Pharmaceutical representatives for each one of these drugs come to our office each claiming some unique clinical advantage of their products over the competitors. They have a tough job since the medicines are all excellent, are priced similarly and are safe. On some days we will have 2 or 3 reps visiting us, each one proffering a medical study or two that supports their product. They show us graphs where their drug is superior to the others regarding an event of questionable clinical import. Their goal is to show that the graph line of their drug is going up, while those of their competitors are going down.

Physicians, like me, who do give these folks some time, have mastered the art of the slow head nod as the drug’s virtues are being related. In the past, the relationships they cultivated with us translated directly into prescriptions being written. Not so today, when our prescribing pens are controlled by insurance company formulary requirements. Those drugs that are not on the coveted list not just swimming upstream, they’re trying to scale a waterfall.


Drug companies know a lot more about us than we know about them. They have detailed prescriber information about what we are prescribing to our patients. Though I assume they don’t have specific patient identities, they purchase date enabling them to know how much Nexium, for example, I am prescribing. This information is used by the companies to motivate their reps. “Kirsch is prescribing Nexium to only 20% of his reflux patients. We need him at 30% by the end of the year.” Drugs reps, who are hired for their extroverted personalities and communication skills, become tongue twisted or even mute if this issue is raised with them.

One of physicians’ most exasperating waste of time is handling calls from pharmacies that the heartburn drug we prescribed isn’t the ‘preferred medicine’. There is no way that a busy medical practice can keep track of the drug coverage preferences for every insurance, company, particularly since these lists change regularly. When the pharmacy calls us, we have to review the record and then change to the new drug, if this is medically acceptable. This takes an enormous amount of time, clogs up our phone lines and doesn’t seem to improve any patient’s health. The real fun starts when we try to convince a pharmacy benefit manager (PBM) to authorize a medicine that is not on their magic list. The phone calls and paperwork are designed to discourage all but the most dogged doctors from pursuing the request. Doctors who enter this arena must relish the thrill of combat if they are to have any chance to prevail. Of course, the PBMs have the leverage, but skilled and seasoned medical professional can pierce their armor to achieve a Pyrrhic victory.

On those occasions when I triumph over the PBMs, I bask in the glow of victory. But, no victory is total. At the end of these setbacks and skirmishes, guess who needs the Nexium most?
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