HMO Drug Lists New Focus of Backlash

LaDonna Hayes had lived a normal, active life as a scientist, grandmother and even a mountain climber until a flare-up of multiple sclerosis last summer left her wheelchair-bound, unable to feed herself and dependent on her daughter’s care.

Her doctor prescribed a new drug, Copaxone, to reduce the attacks and prolong her life. But the 50-year-old Long Beach woman couldn’t afford the $1,000 monthly cost and her managed-care company refused to cover it.

“My biggest fear is I’ll have another attack like I had and this time I won’t even be able to sit in a wheelchair afterward,” she said.

For people with chronic illnesses--diabetes, high blood pressure, schizophrenia and Parkinson’s disease, to name a few--the correct medication can prevent or postpone devastating complications and extend life. But managed care often won’t pay for the drugs.

Health plans, medical groups and other providers of managed care frequently urge doctors to prescribe instead from limited lists of drugs called formularies. Proponents of managed care maintain that such lists can guide doctors to improve care for patients and control costs.

If the drug isn’t listed, doctors may be required to seek special approval, or may have their request denied.

As a result, formularies have emerged as the major new focus of the consumer backlash against managed care.

The issue grabbed attention in California last year after PacifiCare Health Systems Inc. limited its formulary. Under fire from consumers, state regulators stipulated that patients must be allowed to remain on the medications they were taking when the Santa Ana company acquired rival FHP International Corp.

In the spring, Citizens for the Right to Know, a Sacramento lobbying organization that represents groups of practitioners and chronically ill patients, found that the vast majority of 49 California health maintenance organizations surveyed have formularies and that only a few will pay for anything a physician prescribes.

Chronically ill patients and others denied medications have flooded state legislators with calls and letters. Lawmakers and state officials have responded with promises of more regulation of HMOs’ formulary practices.

Advocates for the mentally ill persuaded the state’s Medi-Cal program last fall to add newer treatments for schizophrenia to its formulary. The costlier, newer drugs such as Risperdal and Zyprexa don’t have the severe side effects of some of the older medications.

Last week, Gov. Pete Wilson’s task force on managed care recommended that HMOs be required to publicly disclose their formularies and provisions to deal with patients who take drugs that become delisted. Later this year, he’s expected to act on legislation that would implement such changes.

“This is the year that something will happen in the prescription drug programs of HMOs,” predicted state Sen. Herschel Rosenthal (D-Los Angeles), a sponsor of key legislation.

Even so, some patients with urgent needs have been taking matters into their own hands.

Hayes, for example, went to extremes in fighting for her drug. Luckily, she still had use of her hands and possesses a scientist’s knowledge of her own disease, so she was able to launch a six-month letter-writing campaign to persuade her HMO to cover the medication.

She enlisted her neurologist, the drug’s manufacturer and her employer, the federal government, to help make her case.

Three days before Christmas, she got the OK. “This gives me a fighting chance,” she said.

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Managed-care companies argue that formularies cause doctors to think twice about prescribing a new drug whose benefits have yet to be widely proved. They’re also seen as a way of holding down health-care costs and discouraging doctors from falling prey to drug company salesman who may push some costly new therapy when the standard, cheaper drug will do the trick.

“The consumer benefits, because their physicians gain familiarity [with selected drugs] instead of dealing with the 10,000 or 15,000 drugs in the marketplace. The consumer also benefits from lower premiums,” said Matt Nye, staff assistant to Kaiser Permanente’s pharmacy director.

Said Alex Gilderman, PacifiCare’s director of clinical services: “You have to think of the formulary as a process--a process of adding, reviewing and deleting drugs.”

Among other things, managed-care advocates say the process can help discourage physicians from overprescribing medications such as antibiotics--a practice that can lead to more drug-resistant diseases.

Managed-care advocates also point out that coverage for cutting-edge drugs varies widely among health plans. And many eventually adopt new therapies, especially in Southern California, where competition among plans is intense.

Critics say formularies give managed care an excuse to save money. Activist Jamie Court of Consumers for Quality Care, a Los Angeles-based advocacy group, says many individuals throughout the managed-care system--at the HMO, the drug benefit program and the medical group levels--receive financial incentives to avoid high-cost, often high-relief, drugs by adhering to the list.

“Patients face many obstacles to getting the most effective remedies if those drugs are costly,” Court says. “Physicians, managers of pharmacy benefits and other HMO bureaucrats who must approve those drugs all have financial incentives to withhold high-cost drugs.”

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Opponents also say formularies are penny-wise and pound-foolish for the health system.

They cite a University of Utah study of thousands of HMO patients with chronic illnesses such as hypertension, arthritis, asthma and ulcers that found that patients on strict formularies tended to use more drugs, visit the doctor more often, and end up in the emergency room or hospital ward more often than those whose medications weren’t restricted.

Patient advocates say it’s difficult to discover basic information about which drugs health plans allow, disallow or permit under certain conditions.

Last year, the Los Angeles chapter of the Alzheimer’s Assn. polled major HMOs to find out if they covered two drugs--Cognex and Aricept--that can delay the onset of the disease’s more serious symptoms.

Several didn’t respond, despite letters, follow-up calls and numerous messages, said Michelle Wolf, the chapter’s public policy director.

“It’s really hard to get people to give us a straight answer,” Wolf said. “A big problem was getting the right person on the phone to talk to us. The people we spoke with were afraid to go on the record and state their policy.”

Though the association says many plans now cover the Alzheimer’s drugs, Howard Owens, a lobbyist for California’s elderly, said most HMOs require doctors to make special requests for Aricept, the newer of the two drugs.

“HMOs say it’s available, but seniors complain [that] their doctors say they need it but haven’t yet gotten permission for it,” Owens said.

Practitioners say health plans and medical groups often make them jump through numerous hoops before approving a newer, more-expensive drug.

Joan Werblun, a UC Davis nurse specializing in diabetes, said, “They make us justify to them that we have tried all the other therapies, that you’ve gotten to the point where you are giving the maximum dose of those older drugs but the patient is getting sicker.”

Many people don’t find out that a drug isn’t covered until they get to the pharmacy.

On a recent evening, a mother stopped at Foothill Ranch Pharmacy in Orange County to fill a prescription for Ambien, a sleeping medication, for her 20-year-old son, said Tom Malec, the pharmacist. The young man, just released from a psychiatric hospital, was also taking tranquilizers.

Malec said practitioners have told him that patients on Ambien may have fewer risks of drug interactions than those on other sleep-inducing drugs. But when Malec checked with the family’s health plan--PacifiCare--the plan denied Ambien, which costs about $60 a month, and said it would authorize only two generic alternatives, each of which costs about $2 a month, Malec said.

One of the two alternatives, triazolam, can cause amnesia in elderly patients, and federal regulators have considered removing it from the marketplace because it’s potentially addictive.

Malec said he tried calling the young man’s physician but couldn’t reach him, and the mother ended up paying the $60 out of her pocket.

PacifiCare’s Gilderman said the company discourages the use of sleeping drugs in general because they’re potentially addictive. He said it recommends against triazolam for the elderly.

Newer, more costly drugs may offer subtle benefits that don’t pay off immediately--perhaps not for decades.

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Last year, for instance, a new insulin called Humalog became available. Physicians say it’s a struggle to persuade managed-care plans to approve a prescription, which goes for $35 to $50 a month. But they say the drug can help diabetics better control their blood sugar levels, which is critical to preventing long-term complications leading to possible blindness or amputation.

Dr. Francine Kaufman, an endocrinologist at Children’s Hospital in Los Angeles, said traditional insulin products, which reduce blood sugar levels, must be injected 30 minutes to an hour before a meal. Many patients don’t benefit from those products as much as they should because they eat too soon after injecting themselves, she said.

“Imagine the average teenager getting up an hour before breakfast just because of high blood sugar,” she said. Humalog can be injected 10 minutes before eating--a benefit that means youngsters with diabetes can look forward to being “healthier throughout their entire lives,” Kaufman said.

Managed-care companies say they leave it up to doctors to prescribe what’s best for the patient. But critics say that isn’t true.

One Sacramento gastroenterologist said three in 10 of his patients who should be taking the anti-ulcer medication Prilosec wind up on something else.

“It’s one reason or another--either price or the drug isn’t authorized or I just got fed up and put them on something else,” said the doctor, who insisted on anonymity because he fears that HMOs will quit referring patients to him.

Such fears are not unfounded, said Kathy Perry, a spokeswoman for Citizens for the Right to Know.

“For many of these physicians, their prescribing patterns are being watched very closely, both by medical groups and health plans,” she said. “If they are noted as prescribing expensive drugs and more of them, they can be penalized both financially and through loss of a contract.”

Dr. Vincent Fortanasce, a Los Angeles neurologist, said he’s been taken to task several times for his outspoken opposition to drug policies and other practices of the managed-care industry. He said a contract manager for a medical group that refers HMO patients to him threatened him recently, asking if “I

wanted to see myself with an empty office.”

He said he told the manager, “What I try to do is what I would do for my own mother, my own family and what I would do for you.”

Like much else in health care these days, a patient’s access to cutting-edge therapy ultimately depends on what the patient can afford. Among the minority who pay out of pocket is the chief executive of a large corporation who was diagnosed with Alzheimer’s five years ago.

His doctor, Rodman Shankle of Newport Beach, credits drugs--a $120-a-month prescription for Aricept, combined with some cheaper medications--for staving off the disease’s end-stage effects.

Said Shankle: “He just closed a $100-million deal, so he’s quite functional, but he would not be without the drugs.”