By Michael O’Connor
Vermont’s patients aren’t “one size fits all,” and their choices in prescription medicine shouldn’t be, either. A single prescription drug formulary structure has been proposed for Vermont, but it just doesn’t make sense for patients and the state. Inefficient for patients, financially ineffectual and administratively burdensome, a single formulary system makes it harder for patients to receive the care they deserve at a cost that makes sense.
As background explanation, a prescription benefit management (PBM) plan makes contracts to lower the price of drugs purchased for the state, but they can also limit a patient’s options for treatment, especially when there are several kinds of medications available to treat the same condition. Those limitations, or formularies, can make it harder for patients to receive the right medication at the right time, or remove the best available medication from the management plan.
If cost savings are the premise for such dire risks to patient health, then let’s take a hard look at the facts. Spending on innovative medicines makes up only about 3.5 percent of all federal spending in Medicaid. Professional services, hospital care, administration, home health, nursing facilities and residential care make up the remainder.
Patients may have a trial and error process when they fill a prescription, which may lead to non-adherence with a prescribed treatment plan. For instance, under a single formulary, a patient takes his prescription to be filled by a pharmacist, only to be told that the medication is not covered. Leaving the pharmacy without their medication can derail a therapeutic plan, and in the end cost the patient and the state more.
We understand the state’s need to try to reduce costs associated with health care, but there are other ways to achieve those ends. Adding another layer of bureaucracy could make it harder for physicians to do their jobs and ultimately could have a negative effect on patient care.
Medicines aren’t always interchangeable, and the limitations of a single formulary and substitutions that would be required can have a dire effect not just on patient choice, but on their overall health. As a 2009 Health Affairs article (http://m.content.healthaffairs.org/content/28/5/w832.full) cited, in addition to projected cost savings due to a single formulary being murky (at best), limitation on a patient’s drug formulary can have clearly negative therapeutic effects.
The treatment of Parkinson’s Disease and its side effects requires a delicate balance of prescription medications. Substituting less expensive or generic drugs, or not being able to obtain the correct combination, can often undermine progress made over a long period of time, which makes having the right choice of prescription drug plans absolutely critical for these individuals.
Vermonters who have prescription drug plan options available through Medicare Part D are able to make educated, informed choices about which plan provides them with the best, most affordable coverage. But a single formulary will eliminate this choice and would impact low-income Medicare beneficiaries the most.
Shutting out patients from a physician’s primary treatment decision isn’t the right answer for Vermont. Let’s rethink our approach. It’s not just about how we approach costs; a single formulary is also relevant in thinking about how we pay for value and care for our patients.
Michael O’Connor is the president of the Vermont Chapter American Parkinson’s Disease Association, Inc. and a resident of Williston.