As seen on the op-ed page of the Orange County Register
Cheaper medicines not always better
By PETER PITTS
President, Center for Medicine in the Public Interest, former associate FDA commissioner
Savings on drugs often result in higher costs in other areas.
The health care reform debate has been focused almost entirely on just two broad issues: the large uninsured population and the rising cost of care. But there's another problem that plagues our health system, and it's just as serious. Doctors are losing their ability to treat patients without being obstructed by outside parties.
Any discussion about improving our health system must recognize that rules which empower bureaucrats to get in the way of the doctor-patient relationship are a serious threat to the quality of medical care.
A strong, trusting relationship between doctors and patients is crucial to a well-functioning health care system. Without such a bond, serious conditions might go misdiagnosed or improperly treated, patients might give inaccurate medical histories, or doctors' orders might be ignored.
This is no small problem. Failing to follow a prescribed treatment regimen – a practice known as "nonadherence" -- costs the U.S. health system over $100 billion a year in avoidable medical costs. And, according to a study published last year in the Annals of Internal Medicine, patients who don't have a close relationship with a single doctor are less likely to receive the proper tests for preventing chronic illnesses.
Yet some policies that are gaining popularity are weakening the doctor-patient relationship by putting treatment decisions in the hands of third parties.
Chief among these schemes is "step therapy." Also called "fail first," this is a policy that is sometimes adopted by insurers and government health programs to save money on pharmaceuticals. It forces patients to try cheaper alternatives to a prescribed drug before they are permitted to get the medicine that their physicians ordered.
So even though a doctor might recommend drug A to treat a patient's hypertension, an insurance company or government program would require the patient first try cheaper drugs B and C, and only after the cheaper drugs are shown to be ineffective can the patient receive the medicine his doctor recommended.
There are several reasons such a policy hurts our health system. For one, it is an assault on the relationship between physicians and patients. When a doctor decides on a treatment, he is employing years of medical experience and weighing countless factors, like the patient's age, diet, and lifestyle. Patients, meanwhile, trust that the doctor knows best.
When it's possible for a health care bureaucrat to override the decision of a trained medical professional, this valuable association between a patient and his doctor breaks down. A patient is no longer under the care of single medical expert, but is now being treated by faceless organization looking to cut corners.
This breeds distrust among patients, but it also results in worse medical outcomes and higher overall costs.
One study of schizophrenia drugs used in Georgia's Medicaid program showed that, while step therapy saved the state close to $20 a month on drugs for every patient, the savings were more than offset by increased costs in other services. Indeed, the program saw a monthly increase of nearly $32 per patient in outpatient care.
Similar studies have shown that private plans utilizing step therapy saw hospital and emergency-room visits increase, resulting in higher overall costs.
What's troubling is that step therapy is becoming more widely adopted. In 2000, 20 percent of private insurance carriers used step therapy. By 2008, it was half.
Reformers need to recognize that policies giving health care administrators control over treatment regimes are hazardous to patient health, and actually inflate overall costs.
The deterioration of the doctor-patient relationship is a serious threat to our health system. Ending step-therapy programs is one way to fortify this relationship.
