By Dr. RODOLFO MOLINA
If you get sick or suffer from a chronic condition, you expect your doctor to prescribe the treatment most likely to make you better. As a physician, that's certainly what I want to do.
Unfortunately, in medical practices across the country, doctors are daily being forced to set aside their professional judgment and settle for second (or third) best.
The organizations second-guessing doctors, telling them what they can and can't prescribe treatments, are called Pharmacy Benefit Managers, or PBMs. They have the authority to tell a doctor to "try again" if they deem the cost of a recommended treatment too high. PBMs "authority" comes from their power to deny payments for medicines.
They can even demand that a doctor first demonstrate a patient's failure with a cheaper alternative -- or multiple failures with multiple cheaper alternatives -- before granting access to the doctor's initial choice.
This "cost-effective" approach to health care, which has impacted every medical specialty from mental health to rheumatology, is aptly called a "fail-first" policy.
While this benefits insurance companies, who make more money when patients are forced to take generic drugs, doctors and patients end up paying.
Forced to jump through additional bureaucratic hoops such as detailed paperwork, follow-up phone calls, fax and e-mail correspondences, physicians annually spend approximately $25,000 worth of their uncompensated time tending to tedious PBM requirements.
Patients pay in physical and emotional suffering.
One type of treatment that almost always qualifies for a "fail-first" policy are the biotech medicines, commonly known as biologics. These treatments are more expensive than traditional, "chemical" medicines, largely because they're created with proteins from living organisms.
They are also some of the most scientifically-advanced treatment options available. From fast-moving cancers to cardiovascular disease, biologic drugs have been enormously effective in the fight against many life-threatening and chronic conditions. They're usually administered via injection in a medical facility.
Take Remicade for example, a biologic approved by the Food and Drug Administration for a variety of conditions, including ulcers, psoriasis, rheumatoid arthritis and Crohn's disease. The medicine is expensive -- it costs approximately $20,000 per year -- and for a small number of my patients, it's the best treatment option.
Each time I've prescribed Remicade, I've run up against PBMs that refuse Remicade as a first choice -- insisting that patients instead try a less expensive alternative, even though I'm the one that knows my patients, their histories and what ails them.
Other rheumatologists who prescribe Remicade have faced intrusive audits and huge punitive fines from TrailBlazer Health Enterprises, the organization that administers Medicare and Medicaid in Texas. For all of us, deciding to prescribe an expensive medicine like Remicade too often results in a nightmare of paperwork.
Unfortunately, this is only becoming more and more commonplace.
Two biologics used by ophthalmologists, Lucentis and Avastin, are currently being studied by the National Institutes of Health in a side-by-side comparison for their treatment of an eye disease, age-related, "wet" macular degeneration.
Lucentis is specifically designed and FDA approved for this purpose. Avastin is a popular cancer drug, and has demonstrated great promise in the treatment of age-related, "wet" macular degeneration.
Lucentis, however, costs $2,000 per injection -- approximately 40 times more than Avastin.
Studying these two drugs side-by-side is important. But because the government is underwriting this study, many fear that Medicare and Medicaid will use the results to favor one drug over another -- forcing doctors to ensnare their patients in yet another "fail-first" trap.
When "fail-first" policies fail, it's not the treatments themselves or the PBMs patients blame, it's their doctors.
To protect the autonomy of medical experts as well as the patients who rely on them, these mandatory "fail-first" policies must go.
* Dr. Rodolfo Molina is a member of the Bexar County Medical Society Legislative Committee, president of the South Texas Association of Rheumatologists and practicing rheumatologist in San Antonio.
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