Many practitioners, both prescribers and pharmacists, responded to Tuesday’s article The System is Broken. Most were in agreement with the frustrations described, and many had experienced similar issues with their own patients. Some pointed out that the immediate release guanfacine’s labeled indications only include hypertension while the extended-release guanfacine, a more expensive formulation, is indicated for ADHD. This is an excellent point. It likely explains PBMs rejection of the prior authorization requested by the prescriber. It is also an excellent example of the need for practitioners and PBMs alike to use clinical judgement.
It is about the Patient
So why would the prescriber have ordered the immediate release guanfacine 1 mg twice a day instead of the a once-a-day 2 mg extended release version? The answer is simple: you treat the patient, not the monograph. Is the patient receiving safe therapy, is the therapy effective, and are they achieving the desired therapeutic outcomes? In the case here, then patient has been stable on the therapy for quite some time and has been achieving their therapeutic goals. It was only a change in insurance (a new Medicare Part D plan) that occurred on January first that precipitated the problem.
The resolution to the problem was to change the patient’s therapy to meet the PBMs arbitrary rules. This change, however, has consequence:
- The patient will require additional monitoring (which will likely include visits additional office visits to the prescriber) to ensure the change continues to achieve the therapeutic goals.
- The extended release version of the medication, while being available generically, costs significantly more (in excess of $200 per year) than the immediate release version.
To summarize: the patient was to be moved to a different version of the same drug based only on the existence of an official indication. The PBM applied little, if any clinical judgement (a fact that is further highlighted by their recommendation to use metoprolol, a beta blocker, for hypertension when the patient was already taking atenolol). What is worse, the PBM is not responsible for added costs to patient care that resulted from the change: Medicare Part B will shoulder these costs. Not only does this change cost Medicare Part B, it also costs the drug plan (Medicare Part D) more.
So remember: treat the patient, not the symptoms. Medicine and pharmacy are much more than memorizing and applying recipes. Our patients are real people. We have to think. Follow the simple mantra of Is the patient receiving safe therapy, is the therapy effective, and are they achieving the desired therapeutic outcomes? Doing this is one more way to make every encounter count!
