Pharmacy madness.

The patient had only minor shortness of breath upon climbing two flights of stairs, despite a left ventricular ejection fraction of 30%. He was stable and doing well on digoxin, diuretics, beta blockers and an angiotensinconverting enzyme (ACE) inhibitor. However, a troublesome dry cough was becoming intolerable to the patient. After discussion with him, we elected to consider a trial of an angiotensin receptor blocker in place of his ACE inhibitor. Accordingly, I wrote him an appropriate prescription for an angiotensin receptor blocker for this threemonth trial. That afternoon, I received a voice-mail message from his local pharmacy. I returned the call, fully expecting to discuss a suggested change to another “sartan.” Instead, I was surprised by the information that the patient’s health care plan did not have an angiotensin receptor blocker on its formulary. I was especially troubled because he belonged to one of the largest health care plans in northern California. I was told by the pharmacy that I had to call the plan’s formulary number directly to plead my case for the change in medication. Accordingly, I called the number. After a series of sorting through recorded telephone prompts, I was told that I needed to hold for the next available “pharmacy technician.” Every 30 seconds, a recorded message assured me that my call was important, and extolled the virtues of the health care plan. However, a second recorded voice occasionally told me that this was a busy time and that maybe I ought to call back later when it might be less busy. By now, I was determined to see this through to its conclusion, to understand the magnitude of this pharmacy madness. Twenty minutes later (by the clock), a “pharmacy technician” came on the phone. After I explained the situation, it was clear that the “pharmacy technician” had no clue about the difference between an ACE inhibitor and an angiotensin receptor blocker. I was told to hold while he checked. About one minute later, he came back on the line and I was told that I could substitute a specific angiotensin receptor blocker (different from the one that I had prescribed). When asked why that particular angiotensin receptor blocker was okay (price? efficacy? pharmacokinetics?), but yet not on their formulary, the pharmacy technician indicated that he didn’t know. He did give electronic approval and told me if I called the local pharmacy back in a few minutes, they could access the “approval.” Accordingly, I did this, and the man subsequently received his medication. The whole episode took 45 minutes to an hour of my time to effect a simple change in my patient’s medication schedule. Unfortunately, episodes like this are becoming increasingly common. It is the norm to get 10 to 20 faxes a day from pharmacies asking for renewals or a change to a different “approved” drug. Not uncommonly, I receive letters trying to “educate me” on why, in a given patient, I should switch from one drug to another in the same class. At our academic institution, the outpatient pharmacy was closed because it lost too much money. I sit on our Pharmacy and Therapeutics Committee, which approves new drugs. The ONLY criterion for formulary approval in a given class is PRICE. New drugs face an incredible barrier to being approved unless they are cheaper. There is a circulating pharmacy SWAT team whose goal is to reduce inpatient pharmaceutical costs in specific areas. Patients also contribute to pharmacy madness. Frequently, I need to write two prescriptions for the same medications, so that the patient can send one of them to a mail order pharmacy. Depending on the particulars of their pharmacy charges or reimbursement plan, patients ask me to write prescriptions for all of their OTC medications. The price of medications prompts some patients who have difficulty paying for medicine to ask (and sometimes beg) to receive free samples, and as many as possible. When I write prescriptions for multiple medications for elderly patients, I have grave concerns about their compliance and their ability to pay for the medications. In reviewing all of the above, I believe that PHARMACY MADNESS has gone too far. In order to restore rationality to this process, it seems to me that certain principles need to be considered: