Who’s the Boss--the Doctor or the Prescription Plan?
It was one of those telephone messages I don’t like to get. An abnormally cheery voice on my answering machine said there was “a change” in my prescription plan with PCS. She gave an 800 number to call to find out what it was.
I feared the co-payment was being raised. But when I called back, they wanted to change my blood pressure medicine from Vasotec to Zestril. The co-payment would actually be a little less.
The PCS rep said Zestril would cost its plan less and it had all been discussed with my doctor. Besides, the change was voluntary.
Well, I responded, I wasn’t going to change anything until I talked with my doctor, Ray V. Matthews.
When I did, Matthews said he had nothing against Zestril, a medicine in the same class. But I’d been taking two Vasotec tablets a day for years. We knew it worked, and we’d have to experiment to decide the Zestril dosage. There might be a period of uncertainty.
Thinking “if it ain’t broke, don’t fix it,” I decided not to change. And I told PCS to contact me henceforth only through my doctor.
But I asked my pharmacist, Brad Luton, what the price difference was. He said that under his agreement with PCS, Vasotec costs 87 cents per tablet, while Zestril runs 79, a difference of 8 cents per pill.
All this for only 8 cents? I thought.
But PCS, the largest prescription plan in the United States, with 56 million enrolled, told me that considering their entire caseload, the difference would be a lot of money.
Nick Schulze-Solce, a doctor and PCS vice president, and Blair Jackson, a spokesman, said PCS has 131,000 patients on Vasotec and 171,000 on Zestril. If all 131,000 were to transfer from two Vasotec tabs a day to two Zestril, the annual price difference would be $7.65 million.
No wonder the prescription health care firms of the United States are making a big move to try to shift patients to cheaper medicines.
Although there are sometimes clinical reasons for a change, PCS’ Schulze-Solce said in this case, “it comes down to cost only.”
But, often, he acknowledged, PCS encounters resistance. He and Jackson had no statistics on the Vasotec-Zestril switch, but for all the medicines PCS is trying to change, soliciting required approvals from both doctors and patients, they said the acceptance rate is only between 10% and 20%.
This would not surprise lawmakers in Sacramento hearing from unhappy constituents.
Two restrictive bills, effective Jan. 1, were signed last month by Gov. Pete Wilson.
Assemblyman Martin Gallegos (D-Baldwin Park) is the author of one, requiring prescription plans to continue to pay for a drug, even if it has been removed from their approved “formulary” list, as long as it has been previously prescribed for a patient by his physician.
It is considered a rather mild reform, as is the other bill, by state Sen. Herschel Rosenthal (D-Los Angeles), adding safeguards against improper changes and requiring more disclosure.
Neither of the bills do anything to end the moves by PCS and others urging voluntary approval of changes to cheaper drugs.
Some doctors are outspoken opponents of the process.
Stephen Spreiter of Napa, for instance, has written his 500 patients that the proper practice of medicine is threatened.
“Blood pressure medication is a good example,” he told me. “You may be asked to switch to a similar drug. But it may not entail the same dosage in milligrams. Your blood pressure may rise to limits that endanger you, necessitating more surveillance by the doctor as he makes that change. There may be adverse interactions with other medicines and side effects.”
Thomas W. LaGrelius of Torrance, head of a group of 80 South Bay doctors resisting managed care concepts, said he “absolutely refuses to change medicines on the request of an insurance company.”
“Legally speaking, the only person responsible or suable if anything goes wrong is the physician,” he said, and he asserted that the moves for changes raise questions about PCS and others illegally practicing medicine without a license.
Even though PCS says it has its own doctors approve its recommendations, LaGrelius asked:
“Have they got a license to practice in California? Have they seen the patient? Do they assume the legal responsibility?”
I put those questions to PCS’ Schulze-Solce.
“We do not practice medicine,” he responded. “And we do not see the patient. That is why we do not make these changes mandatory. We leave the responsibility with the physician. It’s their final call.”
In other words, no, PCS is not opening itself to lawsuits.
Ronald Joseph, the director of the state Medical Board, agreed with PCS that this is not the practice of medicine without a license.
“The crux is, it is not mandatory,” he told me. “They ultimately allow the physician to make the decision. If that is the case, it would appear they are doing nothing more than extremely aggressive marketing. . . . The physician-patient relationship is maintained.”
But is it really up to one’s doctor to decide on a change?
Maybe, not exactly. My own doctor, Matthews, suggested communications from PCS and other health plans on such changes may be a little intimidating.
“The implication is that if I don’t change it, I may be taken off their rolls,” he said. And these calls are not infrequent. In a relatively short period last month, his office got 34 calls asking for changes.
The PCS officials responded that, in fact, Matthews had signed a statement with them approving a change for me from Vasotec to Zestril. They wouldn’t even have called me for my OK without this happening, they said.
But Matthews said he didn’t recall signing anything on me.
“It’s possible that my office handled this without me knowing about it,” he said. “As far as I know, I never saw it.”
Jackson said PCS would send a representative to Matthews’ office to check on exactly what had happened in this case.
In the meantime, I’m still on Vasotec and intend to stay on it.
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Ken Reich can be contacted with your accounts of true consumer adventure at (213) 237-7060, or by e-mail at ken.reich@latimes.com
