Working through formulary exclusions

Ethics Forum. Dec. 1, 2003.

What to tell patients about formulary changes

The managed care organization you contract with has changed its formulary, eliminating specific brand drugs in several classes. Some of your patients have been using the discontinued brand drugs with satisfactory results. What do you tell these patients?

Reply:

This vignette illustrates a problem commonly encountered in clinical practice. According to one study published in the New England Journal of Medicine, prescription drug spending in the United States reached $91 billion in 1998 and increased by 17.3% between 1999 and 2000. Managed care companies developed formularies as a means to curb these runaway costs.

Medications are typically chosen for formularies by review boards that evaluate the literature to determine the efficacy of medications. Those found to be unique in efficacy are chosen; those found to be clearly inferior are not selected.

When multiple agents of comparable efficacy exist in the same drug class, e.g. statins, the drug(s) with the lowest cost is placed on the formulary.

The formularies are often viewed by physicians as obstacles to optimum patient care -- they engender patient conflict, increase the amount of nonpaid office work, and limit physician autonomy. Increasing effective communication between the physician, patient, and managed care organizations could circumvent or at least ameliorate the sources of frustration that detract from health care delivery.