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medpundit |
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Saturday, September 07, 2002If federal law constrains states' ability to implement the kinds of prior authorization programs that are routinely used in the private sector, then the law should be changed. Specifically, I believe Medicaid recipients with mild or moderate GERD should have to try an H2 receptor antagonist before being given one othe proton pump inhibitors. Medicaid recipients with osteoarthritis and low risk of GI problems should be required to try a generic NSAID before being given either a COX-2 inhibitor or a brand name NSAID. Medicaid recipients suffering from depression should be required to try fluoxetine HCl before being given a patented antidepressant like Paxil or Zoloft. After Claritin loses its patent later this year, Medicaid recipients who are suffering from allergies should be required to try generic loratadine before being given one of the patented non-sedating anithistamines. And if a number of competing drugs are very similar to each other with respect to both clinical efficacy and side effects (e.g., statins), it makes sense for the state to put the lowest-price drug(s) within the therapeutic class on its preferred drug list. There will be complaining from the usual suspects--e.g., doctors who believe their autonomy is being compromised, patients' rights groups who believe the restrictions will harm patient health, and of course the pharmaceutical industry, which will assert that the reduction in reimbursements will reduce innovation. But at the end of the day, I think these requirements would likely have little or no adverse effect on patients' health--any patient who does not respond well to the preferred drug could be switched to a more expensive non-preferred drug. And Medicaid drug costs would probably plunge. For example, according to a New England Journal of Medicine study published a few years ago, when Tennessee implemented a fail-first requirement for brand name NSAIDs, its NSAID expenditures dropped by about 50 percent. The evidence is not definitive--these programs have not yet been widely studied, and the NEJM study of Tennessee did not include a "control" state--but my guess is that these programs are as close as we can get in health care to a "free lunch": that is, dramatically lower costs with almost no adverse effect on patient health. I agree. I would like to be able to say that the majority of physicians choose drugs based on their efficacy rather than on detailing by drug reps, but the sad truth is that with each passing year I become more and more aware that the prescribing patterns of the majority of my colleagues are based on drug rep hype. Yesterday, a neurologist started a patient of mine with a normal cholesterol on a statin to treat her homocysteine level. I'm worried that she'll end up with liver problems or an interaction with her other drugs. My own husband came home last week from his doctor with a new, expensive antibiotic for pneumonia when a cheaper, older one would have been just as effective. All of my patients who see orthopedists or rheumatologists for their tendonitis or arthritis come back with Celebrex or Vioxx rather than ibuprofen or naproxen. Everyone wants to give the appearance of being on the "cutting edge" of medicine by prescribing the newest therapy, without regard as to whether or not it's actually any better than the old. The medical profession has abdicated a great deal of responsibility in this regard. The choices of the drugs we use to treat and prevent illnesses have far greater public health consequences than issues like obesity and alcohol use which have come to dominate the public health arena. posted by Sydney on 9/07/2002 06:32:00 PM 0 comments 0 Comments: |
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