Dispensing Opinions on Health Plans’ Drug Formularies

“HMO Drug Lists New Focus of Backlash” [Jan. 18] lists complaints by physicians and patients in managed-care plans that doctors are required to prescribe drugs only in the plans’ formularies and that they are unable to prescribe drugs which they consider to be the best for their patients. This is blatant interference in the way physicians can practice. Most likely, one of the reasons is that some drugs are expensive and their use would affect profits, which should have no role in medical care.

SOL LONDE, M.D.

Northridge

*

The Times had an opportunity to educate readers about the nuances of prescription drug formularies. Sadly, the piece came up surprisingly short in content and fact. We at PacifiCare feel obligated to pass along some key facts:

First, despite the outcry by managed-care opponents, many practicing physicians accept formularies as a necessary part of health care today. They also help us construct the very formularies we use. The feedback they receive helps them alter their prescribing patterns to make the most of our members’ pharmacy benefit coverage and check against negative drug interactions--neither of which were available under the health insurance of the past.

Meanwhile, drug company consumer advertising will soar to more than $1 billion in 1998 as they look to convince us that their latest offering is what we need for what ails us. Drug cost inflation is now estimated at 16%. That kind of inflation is placing more of the latest wonder drugs perilously out of reach of the average American.

Second, we’re keenly aware of how important prescription drugs are for our members. We have more than 1,600 name brand and generic drugs available and provide such coverage to the nearly 1 million members in our Medicare HMO, Secure Horizons, and to nearly 3 million members in our HMOs. At present, Medicare does not provide such coverage. To make matters worse, the program admitted in a federal audit recently that it had lost up to $447 million in 1996 due to overpayment for the drugs it does cover (primarily immunosuppressants for infections, organ transplants and hospitalizations).

Last year, we at PacifiCare paid more than $350 million for prescription drugs for our Medicare HMO members alone. We know, for example, that the average senior uses 13 different prescriptions annually while Secure Horizons members consume an average of 16 prescriptions--all at little or no cost to them here in California. That represents hundreds, if not thousands, of dollars in savings, while helping our members better manage their health.

Third, formularies are nothing new. Hospitals, physician groups and the government’s Medicaid program have been using them for decades. And for the same reasons--health plans have--quality and cost.

Reading your story, one could assume formularies were something concocted by HMOs solely for controlling cost. That’s simply not the case. Is there a need for formularies today? Absolutely. Responsible HMOs will continue to develop policies with physicians and pharmacy partners to control cost, improve quality and expand access based on the simple credo: the right drug at the right time in the right setting.

SAM HO, M.D.

Vice President for Quality

PacifiCare Health Systems

Santa Ana