The Furlough and the Formulary
The ripple effects of the government shutdown reminded us that it isn’t just government employees who are who are affected by financial uncertainty.
The same can be said for healthcare, and for drug formularies in particular.
From air traffic controllers in metropolitan airports to park rangers in National Parks to restaurant employees in Washington, D.C. to family members and a broad spectrum of contractors, it did not matter. Hard work did not matter. Experience did not matter, neither did a PhD or an excellent attitude or affiliation with a political party. They were all hit with undeserved consequences.
What’s the connection? A formulary is an approved list of drugs published by Pharmacy Benefit Managers (PBMs). A brief Kaiser Health News video (https://khn.org/news/little-known-middlemen-save-money-on-medicines-but-maybe-not-for-you/) illustrates the role PBMs have come to play as deciding intermediaries between pharmaceutical companies and health insurers. Drug formularies tend to come out with the new calendar year. The three largest PBMs are currently Cigna’s Express Scripts (the result of a recent merger), CVS Caremark and OptumRx.
If you happen to take a medicine or use a prescribed delivery device or product which is excluded from the formulary it is like being placed on private furlough. It does not matter how hard you work to take care of yourself, or how excellent your overall health is, or if you have needed a medication for two years or twenty years. It does not matter if you have the same employer, health insurer and prescribing clinician as you did last year. The PBM blocks your access and lets you know that if you do not take their preferred medication you are welcome to pay full price. Their preference might change next year if they contract with a different pharmaceutical company. Sometimes this does not matter. A generic drug or another brand might function well for you. If it does not, tough. You can pay for it as if you had no insurance at all. And next year, when new formularies come out, you can wait and see if the medication switches again.
As with the government shutdown, those indirectly affected share the exasperation and sometimes danger. When your child or parent or anyone you are responsible for and care about needs a medication you are also on the hook. Your daily life changes with theirs.
We’re starting to hear more about the exponentially high price of prescription drugs but we rarely hear about other barriers to access. Generics are extremely important, and there is a long haul ahead on the patent protectionism front with pharmaceutical companies and the shareholder-driven decision making of PBMs to get pricing under control. Access is also about getting the right drug or device a patient needs at the right time, in the right dosage.
Last week I was in conversation with a colleague who does not know how she will afford an essential medication because the PBM her insurer contracts with decided that it will only provide the generic even though she does not respond to it in the same way. Bodies are not identical. Generic drugs have the same active ingredients as name brand drugs and they work well in many cases, but not in all cases. Absorption rates vary. The functions of delivery devices vary. Her specialist is just as frustrated as she is because the decision should be theirs, not the PBM who used to cover the drug and then excluded it.
This is not simply a patient problem. The expertise of clinicians is undermined when they no longer get to decide what to prescribe for their patients. “The Insulin Wars,” a January 20, 2019 New York Times article by Danielle Ofri, a physician at Bellevue Hospital is an excellent example of how this hinders the very people who are trained to make these decisions.
“Sick” and “healthy” are not tidy categories. We all age. We move in and out of categories. Those for whom we are financially responsible age. They get injured. They get cancer. They get Hepatitis C or Multiple Sclerosis. They get Crohn’s Disease. They get cancer again. They need EpiPens or antiviral drugs or continuous glucose monitors.
We will all be hearing more about drug pricing and patents and legislation to start changing what has long been a blind spot. It is an issue of collective urgency. It should be the least partisan issue of our time. The sooner we treat it this way the quicker we will begin to improve it.
Katy Giebenhain is a member of the Gettysburg Area DFA Healthcare Task Force