Who's In Charge Of Writing Prescriptions?

Patients, insurance companies and drug companies drive prescription practices

In the old days, physicians examined their patients, diagnosed their symptoms and if necessary, prescribed the most appropriate medications to treat their ailments.

Today, patients, drug companies and managed care drug formularies help determine what medications will be prescribed, reports Texas Medicine magazine in a recent cover story.

While patients used to rely on their physicians for advice, patients now offer advice to their physicians about what prescriptions they think they need. Thanks to highly successful direct-to-consumer advertising efforts by drug manufacturers, it is commonplace for patients to ask their physicians for certain prescriptions by name.

Dr. David Butler, a family practitioner, said he abhors direct-to-consumer advertising.

"It colors the whole encounter. Patients are already set on their treatment, predisposed to a diagnosis," Dr. Butler said.

Pharmaceutical companies will spend nearly $2 billion this year courting patients to ask their physicians about drugs they manufacture. While that may seem like a large price tag, it pales in comparison to the $111.1 billion in pharmaceutical retail sales last year.

Pharmaceutical companies also direct their marketing efforts toward physicians. Drug representatives make frequent calls on physicians, providing them with free drug samples and other gifts, while promoting the benefits of the newest medications.

"Pharmaceutical representatives are leaving free samples of new drugs all the time so it's sometimes easy to forget that older, less expensive, but very efficacious drugs are available," said Dr. Gregg Lucksinger, a family practice physician.

Managed care pressures, namely drug formularies, are also a major factor in prescription practices. Health plans use drug formularies to limit the medications that can be prescribed, and substitute less expensive generic drugs for name brand pharmaceuticals. According to a recent survey of Texas physicians, 58 percent said they have seen specific cases in their practices where managed care policies adversely impacted the quality of patient care. Of those, 75 percent cited restricted drug formularies as a cause of poor quality care, making it the most frequent problem.

Dr. Butler said he tries to prescribe the least expensive option about 90 percent of the time.

"When I want to prescribe something that is not within the managed care plan's drug formulary, my staff has this huge hassle with phone calls and additional paperwork, to do a little tap dance with some HMO to prescribe the drug I think my patient needs. The sheer chaos of it is what's so frustrating," said Dr. Butler.

In addition, physicians say patients often feel less confident about the generic drugs covered by the drug formularies.

"A patient has to feel confident in the drug I prescribe," said family physician Dr. Abe Rodriguez. "For example, if I have to change to a less expensive medication, I have to spend time to explain that it offers the same benefits."

Like everything in health care, the process of prescribing medications is a lot more complicated than it once was. The pressure applied by patients, drug companies and managed care organizations means writing a prescription is not always what's best for the patient.

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©2006 Texas Medical Center

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