Physicians push for cheaper, more accessible medications

The AMA considered a number of prescription drug issues in the context of finding a solution to the problems of drug errors and pricey prescriptions.

By Victoria Stagg Elliott, amednews staff. July 7, 2003.

Chicago -- Physicians at the AMA's Annual Meeting last month made clear their interest in prescription drug issues -- especially those related to linking patients with more effective, less expensive medications and ensuring that these meds are taken as directed.

"We're concerned about the availability of medications for our patients," said AMA President-elect John C. Nelson, MD, MPH. "We are aware of a crisis and that it can cause a hardship for people. We don't want -- in particular our seniors -- to have to make a decision between paying the rent or food and buying their medications."

Online prescribing policy gets specific
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The Association took action regarding the role of pharmacy benefit managers, drug inserts and the refill process.

The AMA will work to develop legislation and regulation to increase the transparency of the business practices of pharmaceutical benefit managers to minimize conflicts of interest with drug manufacturers, health plans, employers and physicians. Doctors complained that all too often that information is proprietary.

"We're not opposed to working with those who have expertise in pharmaceuticals," said Dr. Nelson. "But we feel that some other motive, such as cost cutting, should not take the place of quality concerns."

The AMA also will team up with the Food and Drug Administration to make medication package inserts more readable and will join forces with various associations of pharmacists and drug stores to streamline the refill process. Physicians had complained that this process continues to be too cumbersome.

"I have to take time away from my patients in order to decipher all the different forms," said Anthony Jaspers, MD, a family physician from Lake Crystal, Minn. "The wide variation increases the risk of errors and impacts patient safety."

Meanwhile, the AMA will continue to focus on pharmaceutical shortages. It also reaffirmed its support of FDA-regulated direct-to-consumer advertising. Delegates voted against considering foreign drugs, such as those imported from Canada, as possible relief for patients who struggle with the cost of prescription drugs. They maintained that the FDA imprimatur continues to be a critical aspect of patient safety. "We want to make sure the medications are what they say they are," said Dr. Nelson. "There's no way to control, once the drug has been imported or reimported, how that drug may have been altered."

Still work to be done

On related issues, delegates called on the Board of Trustees to study possible action to resolve concerns about the impact of formularies on patients, therapeutic substitutions, patent extension for pharmaceuticals and the influence of funding on the outcome of drug research.

Some physicians were frustrated by patent extensions that they felt unfairly interfered with the availability of generics and by drug research that might be unduly influenced by the funding source -- whether it was a pharmaceutical company, educational institution or government agency. Delegates also took issue with formulary-motivated drug substitutions at the pharmacy, which they felt undermined patient care.

"This is a patient-safety issue, a quality-of-care issue and interference with clinical decision-making," said Michael Ellis, MD, an otolaryngologist from Chalmette, La. "Drugs are being changed on a weekly and monthly basis, and this is a dangerous situation."

Other physicians, however, felt that careful drug substitutions could save enough money to provide better care.

"Controlling costs is a significant issue," said Rowen Zetterman, MD, a hepatologist from Omaha, Neb., and an American College of Physicians delegate. "By controlling costs at our hospital, we were able to give better care in many areas."

Experts pointed out that extended patents are often in exchange for other services of benefit to medicine.

"Extending patent life has given us orphan drugs and pediatric testing. This is an issue that we need to study before we jump in," said Peter H. Rheinstein, MD, a delegate from the American Academy of Pharmaceutical Physicians.

ADDITIONAL INFORMATION:

Online prescribing policy gets specific

The American Medical Association recognized that online transmission of prescriptions is acceptable within the context of a patient-physician relationship and Web sites that offer prescriptions based solely on online questionnaires may not meet the minimum standards of medical care, according to a Board of Trustees report advanced at the organization's Annual Meeting last month.

"There's an amazing amount of information on the Internet. Some of it's even true," said John C. Nelson, MD, MPH, AMA president-elect and an obstetrician-gynecologist from Salt Lake City. "What this is attempting to do is take good policy and make it better -- stating specifically that Internet prescribing ought to only occur within the context of the patient-physician relationship."

Using the Internet to transmit prescriptions is acceptable when a physician is able to obtain a reliable medical history, perform a physical exam, have a risk-benefit discussion with the patient, provide follow-up and maintain a medical record that includes the electronic prescription information. Exceptions are allowed for situations in which a physician is providing the prescription in consultation with another doctor who does have a relationship with the patient or times when a physician is on call or is providing cross-coverage and has access to the patient's records.

Physicians also should be licensed in the jurisdiction where the patient resides and be able to transmit prescription information over a secure network. Physicians prescribing via a Web site should provide identifying information and any financial interest in the products and recognize that they may increase their exposure to liability if they prescribe only through online interactions.

"Technology can enhance our relationship with patients," said AMA Trustee John H. Armstrong, MD, a San Antonio surgeon. "It can also be a barrier to that relationship. These guidelines relate to how it can enhance that relationship."