While we are all concerned about the high cost of medical care, especially in these intense times of health care reform, one aspect does not change: Doctors must decide what medications and therapies are best for their patients.
Unfortunately, many Missouri patients are told at the pharmacy that they cannot have the medication prescribed by their licensed physician because a pharmacy benefit manager (PBM) or insurance company has denied coverage. This is not the fault of the pharmacists; they are just the ones who have to tell patients they can’t have their prescriptions. That is the reason I have filed House Bill 1700 in the Missouri House of Representatives.
In some cases, the PBM switches the patient to a different, less-expensive substitute. Other times, the patient must undergo a “step therapy,” which may include an over-the-counter regimen — for example, ibuprofen — or a generic medicine as a first step that is determined by the PBM. Both practices can be dangerous for some patients.
Some of the stories I have heard are beyond belief. I had a mother, whose 7-year-old daughter has epilepsy, call my office. Her daughter has a history of having 20-30 seizures a day. The neurologist finally found a medication that controlled the girl’s seizures. The mother recently went to have the prescription refilled and was told the PBM wanted her daughter to do a step therapy. The PBM ordered medications that the girl already had tried without success. Needless to say, the mother panicked.
The mother and the doctor worked diligently to get the girl back on the medication she needed, but not before the child started having the seizures again.
This is the perfect example where we need a system in place to ensure that the practicing physician, who knows the patient’s medical history, can override a step therapy or medication switch.
I have filed House Bill 1700 to address this important issue. It has bipartisan support and is endorsed by the Missouri State Medical Association, Missouri Nurses Association, Missouri Academy of Family Physicians, Missouri Pharmacy Association, as well as numerous patient advocacy groups.
I want to be clear that I am all for generics. Where there is a problem is when a patient is switched to a different formula. In some instances, the new medication contains different active ingredients or it doesn’t provide the same therapeutic benefit.
I also support the use of step therapy when appropriate. This is where there is clinical medical evidence to show why a patient cannot take a medication. The patient should not be put in a position where he either takes a medication he knows will have an adverse reaction, or he is forced to pay the full cost.
If we are going to go for out-of-pocket, then why is the PBM being paid to provide the service?
We all want to contain costs, but it is wrong for PBMs and other third-party payers to force doctors to prescribe medications based primarily on cost to these entities without appropriate regard for the patient’s best health outcome. After all, our doctors are the ones with the license, training, experience and important patient information to decide the best course of treatment for their patients.
Bryan Stevenson, Webb City, is Missouri’s state representative for the 128th District.
