Who is it that really makes the final call on what your treatment is for any of your medical conditions? Most would say their doctor. As a pharmacist however I see something different. It is common to see a patient come to the dispensary counter after their physician has already phoned to see if a first choice drug is covered. Maybe I call the Doctor after I see the prescription and tell them the patient’s plan doesn’t pay for that choice. I see people go without therapy that used to be covered but isn’t anymore. OTC meds are often considered for the most part as “off the radar” for these plans, as if OTC means something useless or not Doctor or Pharmacist recommended. It is often frustrating for medical professionals to feel like their hands are tied and that they are being told what to write for. Newer and more expensive medications that may have obvious benefit over older drugs may be left out in the cold for lengthy waits until a plan decides to cover them. As well, unrealistic hoops may be required to be jumped through before an effective one is covered. It is not uncommon for refills to be made for an unused and ineffective drug that is not taken for weeks or months to show a plan that a drug is being “tried” in order to get the next one approved. Meanwhile the patient suffers needlessly until the more effective one is paid for by the plan. Slow prior approval processes can become mired down in a way that has patients waiting needlessly for letters from physicians, OT’s, and other specialists.
Unbeknownst to the rest of the world is the strangle hold these plans have on pharmacies. While it is true that pharmacies fill more prescriptions when patients have third party plans, it becomes a profit based on volume that puts big chain pharmacies that avoid smaller communities at an advantage and smaller more community minded independents out. Gone are the days when pharmacies had some say in their dispensing fee, now a four letter word to the public but the main way dispensaries make money. Pharmacies used to be and should be able to run based on their pharmacy sales but not so much any more. dispensing fees don’t cover the cost of filling a prescription for most pharmacies. For the first time we are now seeing a decrease in dispensing fees. It has become a take it or leave it contract.
Small communities that have relied on the donations of these strong businesses have seen this drop off or eliminate altogether, reducing spinoff benefits. Keep in mind that small independent pharmacies have a more timely and positive response to the types of charity requests seen daily. Preferred provider contracts give lower prescription prices at specific chains, something that used to be illegal. The drop in pharmacy revenue causes front store prices to climb and customers find themselves paying for services that they assumed should be for free, like tax receipts, refill extensions, med reviews, calling the doctor and consultations – things that we are accustomed to getting gratis.
So, physicians are somewhat dictated to, pharmacies are told their price for what they are selling and who is it that controls your health? Of course there are benefits. Most wouldn’t afford the healthcare they have without their plan and that plan is a business that deserves to have some control over its own costs. It should not be a dictatorship that slowly undermines our entire healthcare model.