When It Comes to the Pharmacy Benefit, You Get What You Pay For: An Examination of Dr. Brewer's Wall Street Journal Editorial

Did you know the Disease Management Care Blog was a former Medical Director in a not-for-profit HMO? In that role, it often got to experience first hand the ‘other side of the story’ when a physician ordered a drug that was subject to utilization review.

To read Dr Brewer’s side of the story, he is being unjustly second guessed by a faceless health insurance company more interested in saving $120 per month than doing right by his long-term patient. He argues these hassles lead to the unecessary use of his and his office staff’s precious time. This is wrecking his margins and ability to accommodate more patients.

While the DMCB sympathizes with Dr. Brewer, here are some inconvenient facts:

Medical Directors in most health plans have the ability to approve tests, procedures and drugs on the spot and to do it quickly – literally with the stroke of a key. The DMCB would venture to guess that 99% of Medical Directors, when presented with the facts in Dr. Brewer’s article, would approve the drug. Dr. Brewer’s travails, while vexing, are the exception and not the rule for most health plans most of the time.

Managed care review of drugs like Celebrex are based on same decision support tools that populate electronic health records. Ironic, hm?

Pharmacy programs that use utilization review (UR) cost less per month than pharmacy programs that don’t. That's because they work. Whoever was buying his patient’s Celebrex-needing insurance benefit probably had the choice of purchasing the more expensive option and did not - despite the physicians' discomfort. That’s because they are less affordable. That means pharmacy programs that have UR are cheaper and more affordable and more accessible.

While the DMCB would probably trust Dr. Brewer, it has had reason to not trust many of Dr. Brewer’s colleagues, who like to prescribe potentially dangerous drugs like Celebrex when a cheaper substitute has been shown to work just as well. That speaks to the fiduciary responsibility of health insurers, which they take very seriously.

It is precisely the angst of physicians like Dr. Brewer and their patients that has caused many insurers to retreat to a tiered benefit design. More expensive drugs like Celebrex can be liberated from the tyranny of UR by a Faustian bargain: hooking them up to higher out-of-pocket cost for individual consumer who really needs drugs like Celebrex.

Finally, the DMCB asks readers to ask why drugs like Celebrex cost $120 per month and if it’s the health insurers’ fault.