Swallowing the right pill, now

Where is Mary Poppins when you need her, she of the “spoonful of sugar that makes the medicine go down”? Were the fetching and perky Miss Poppins commissioner of the Maine Department of Health and Human Services instead of Kevin Concannon (who has never been called perky, even if fetching) perhaps Maine’s doctors would not act as though they had just been given the state’s new prescription drug cost containment “medicine” in the form of a suppository.

That “medicine” is a new DHHS rule that limits doctors’ choices when it comes to prescribing pills for Maine Medicaid patients; the state will not pay for medications that are not on Medicaid’s list of approved drugs unless the doctor gets permission from the DHHS first.

The rules are part of a DHHS effort to rein in the cost of prescription drugs for Medicaid patients, currently about $200 million annually in taxpayer dollars. DHHS hopes that forcing doctors to prescribe for Medicaid patients from its “closed” list of approved medicines will save about $10 million annually. (A “closed” list of approved medications is called a closed formulary.) DHHS has been willing to take on the state’s doctors over the issue because prescription drug costs are increasing at 15 to 20percent per year and the state Medicaid budget is more out of line than the new door I just hung on my bathroom. (It looks like I asked my dog if the door was straight and she looked up from her second bowl of beer, cocked her head to the side, and said “Ayuh!”)

Medicaid’s closed formulary system is a bit like a sweaty gym sock; it smells particularly bad only when examined outside of the locker room. Here is the rest of the dirty laundry:

. A 15 percent increase in the cost of prescription drugs for Maine Medicaid next year will be $30 million. That kind of annual cost increase for taxpayers is unaffordable, and the state must do something to control those costs. Any money the state does not save on the cost of prescription drugs for Medicaid patients must be saved elsewhere. None of the alternatives are pretty, and many others will impose more of a burden on patients. The closed formulary is one of the few choices that does not really limit Medicaid benefits or enrollment;

. Maine’s doctors have demonstrated only limited ability on their own to prescribe medications in a cost-effective manner. Had they already been doing so Maine Medicaid would save little from a closed formulary system. The vast majority of the most expensive medications have good, effective, cheaper alternatives that many doctors fail to use.

Moreover, many of those doctors contribute directly to the prescription drug cost problem by accepting free gifts from the drug companies whose medicines they prescribe, gifts which are ultimately paid for in part by state taxpayers who foot the bills for Medicaid patients. A profession that has largely failed to do its part to control the costs of prescription drugs has a wobbly leg to stand on when complaining that state bureaucrats are interfering in the practice of medicine;

. The pharmaceutical industry has done virtually nothing to leave the state with any alternative to controlling drug costs by other means. It has fought other price control efforts tooth, nail, and lawsuit. The industry has contributed tremendously to the cost of prescription drugs by advertising its most expensive drugs directly to patients, encouraging those patients to ask doctors for more expensive drugs when less costly alternatives might work just as well. Failure of the state’s doctors to support Maine Medicaid’s closed formulary system will allow the pharmaceutical industry to play doctors off against the state, hand another victory (complete lack of price control) to the industry, and send about $10 million annually in unnecessary Medicaid dollars to industry coffers. That industry needs more money like my dog needs Rogaine;

. Spending of taxpayer dollars imposes a greater burden for cost-conscious medication use on doctors, patients, pharmacists, and the state. A closed prescription drug formulary is one way to ensure responsible use of taxpayer dollars;

. Many hospitals have closed formularies, as do many health insurance companies. Closed formularies are nothing new to doctors, even if every closed formulary is a pain. The Maine Medical Association, representing a lot of the state’s doctors, has gone to the Maine Legislature looking for legislative relief from the new rule, feeling that the system stinks. They should not get more than some tweaking of the program; legislators should hold their noses and support the concept.

Our doctors need to step back from their reflexive objections to interference in their practice of medicine and give the program time to work. They need to work with DHHS officials to make the program more patient- and doctor-friendly, adjusting the dose (as it were) of this new “medicine” for maximum benefit with minimal side effects. They need to practice what they preach, namely that some limits on personal freedom (e.g. seat belts) are a necessary evil for a greater good (fewer deaths in car crashes).

The new rules are a kind of seat belt on doctors’ prescribing habits, one that will help prevent Medicaid’s budget from being thrown through the windshield by an annual head-on collision with prescription drug price increases. Medicaid’s closed formulary system may smell a bit rank, but it is good medicine for what ails us. Hold your nose and swallow, Doc.

Erik Steele, D.O. is the administrator for emergency services at Eastern Maine Medical Center and is on the staff for emergency department coverage at six hospitals in the Bangor Daily News coverage area.