M. Calon on the Critique of Wisconsin's Drug Cost Program
Marty Calon, RPh, of Baltimore, Maryland, responds to the critique of Wisconsin’s program to reduce drug costs for state employees:
I usually couldn’t agree more with your comments, but I have to disagree with some of what you say here. I am a pharmacist with long experience in the Department of Veterans Affairs with these prescription practices.
As long as drug companies persist in pricing by dose, whereby a 5mg tablet and a 10mg tablet cost the same, splitting tablets is a viable option, as long as it is not done without controls. The drugs which are suitable for splitting must be specified and selected, on the basis of (in order of priority) suitability for splitting (physically and clinically), cost, and amount of usage (no point in requiring splitting of drugs which are rarely prescribed).
Specifically, there has to be good clinical judgment or clinical evidence that the particular medication and dosage form is suitable for splitting, and there has to be a liberal exception mechanism for patients who cannot or do not wish to deal with the splitting. The splitting program also should be monitored to ensure that the drug therapy with the split tablets is producing the desired results, although this monitoring should be happening regardless of tablet splitting.
For example, SSRIs and sildenafil (Viagra) are ideally suited to splitting. It doesn’t even matter if the dose is not precisely divided, because the exact dose is simply not very important, which is true for many drugs. In the case of SSRIs, which have a long-term effect, it’s just about irrelevant whether the patient gets his precise dose every day; cumulatively, he’ll get the right dose unless the tablet is falling apart. Warfarin is a drug that probably should not be split if possible. Pharmacists have a good understanding of the physical composition of the tablets (coatings, sustained-release mechanism, etc) and their pharmacokinetic parameters to determine their suitability for splitting.
Many physicians don’t have the knowledge, cost information, or motivation to prescribe generically. The majority of medications that are available generically do just fine if the pharmacist selects reputable generic vendors. The handful of notable exceptions (warfarin, theophylline SR, phenytoin, etc) are the only ones that need be limited to brand-specific prescribing. Pharmacists are well-qualified to make these judgments and advise physicians and patients on generic substitution, especially as they have the cost and legal equivalence information that is often not disclosed to physicians.
One more point: Rational selection of the most cost-effective medication, and controlled and monitored therapeutic substitution, again with appropriate exception mechanisms, are even more effective ways to save money. Think of all the people who are taking expensive antibiotics for trivial infections (if they need them at all), and the patients who take expensive “non-sedating” antihistamines and unnecessary COX-2 inhibitors, because they are so heavily promoted. And let’s not even start with all the patients taking medications that they don’t need at all.
I agree that these are not long-term or ideal solutions, and I make no apologies for the so-called “Pharmacy Benefit Managers”, but—properly implemented—they are appropriate responses to the current realities of medication prescribing and its costs.
Don’s response:
I emphatically agree with Marty Calon’s comments. They are certainly applicable to the real world of today, although we would hope might be modified eventually to apply to the ideal world which we envision.
One point that I failed to make was to acknowledge the crucial role that the pharmacist plays as part of the medical team. And I want to emphasize that the role to which I refer is as a health care professional who assists the patient and his or her practitioner in matters regarding drug therapy. This is in sharp contrast to a pharmacy benefit manager (PBM) that is primarily a middleman working the system to maximize profits for the PBM organization. Pharmacists must always be an integral part of the professional medical team.
The other point that I want to reemphasize is that we need fundamental structural changes that will improve access and affordability of prescription drugs. The pharmacist’s role should be to assist with the selection of the most appropriate drugs that also offer the best value. As the paper by Dean Baker demonstrates (a “quote” last week), we need to revise the drug patent system to provide incentives for better value in drugs. But also, we need to use negotiated purchasing that would also eliminate gimmickry designed to enhance profits. And we need to place the pharmacist in a position of being rewarded for applying his or her professional skills, rather than being placed in a subservient role of enhancing the success of a PBM business entity.