There is much discussion around the nation surrounding the topic of prescriptions and their related costs within the workers' compensation industry. Of all the issues, none has as simple and clear a solution as those surrounding the process of physician dispensing. That solution?
Don't allow physicians to fulfill their own prescriptions.
Problem solved – but of course, it is not that simple. It never is when politics is involved. Managed Care Matter's Joe Paduda writes a revealing piece on the process surrounding Florida's SB 668, a bill currently working its way through the state Senate, designed to limit what physicians can charge for dispensing prescriptions. As Paduda discusses, a tremendous amount of money from parties with a direct interest in maintaining the status quo has been injected into the fray. In fact, well over $3,000,000 has been donated to Florida politicians and their committees from “dozens of companies” that are “heavily involved in physician dispensing”.
Why do physicians wish to dispense their own prescriptions? According to a 2010 report from NCCI, there are four basic reasons:
- The physician wants the patient to start taking the drug immediately and dispenses enough medication to last until the patient can get to a pharmacy
- The physician cannot be sure what the right medication or dosage should be, and dispenses a few days' supply of medication to determine whether that course is effective
- It might be inconvenient for the patient to get to a pharmacy
- The physician is looking to increase revenue by retaining some of the business he would otherwise send to pharmacies
I can concede the first two points. The third, being a resident of Florida, I find a bit ludicrous. Look around. You can't swing a dead cat in this state without hitting a pharmacy. I understand the injured worker may have trouble getting around, but in most cases here, they can get to the doctor; they will most likely pass 3 pharmacy's on the way back home. No, the real problem with physician dispensing is item #4 – “The physician is looking to increase revenue by retaining some of the business he would otherwise send to pharmacies”.
And not just retaining revenue. Far from it. Profiting greatly from it would be a better description. Some estimates are that repackaged drugs are sold at 600% increases over what a pharmacy operation would charge. According to a recent article in Risk & Insurance, “The top 15 most frequently dispensed drugs in Florida’s workers’ comp system are 45 percent to 679 percent more expensive when dispensed through repackaging, according to NCCI”. But the price increases have been fairly oft discussed; this is not news to many. While it is a ridiculous, unnecessary increase in costs for the system, it is not my prime concern.
No, my concern is one I find discussed far less often, and broached with much more hesitancy. It is one of utilization: By allowing physicians to dispense their own prescriptions, with profit being a very strong incentive, are we letting the fox guard the henhouse?
I cannot shake a disturbing conversation I had with a doctor several years ago at the FWCI conference in Orlando. This doctor had just relocated to Florida from New York, and primarily performed IME's. Now this doctor, a physician, sworn to the Hippocratic Oath, and who did not know me from Adam, could not stop talking about how much he loved working for a particular carrier. He raved about them, saying that he LOVED to perform IME's for them. He told me that he would “write whatever they wanted”, and they would pay him $1500. He loved that arrangement, which for him was easy and profitable.
Do I think the carrier instructed him what to write? No. I think they found a doctor they could consistently count on, and used him extensively. Do I think all IME's behave this way? Absolutely not. Do I think this scum sucking slimebag would screw an injured worker for fun and profit? Clearly, he would. And do I think that same physician, in the role of primary care, would prescribe unnecessary medications or improper dosages to increase his bottom line?
You bet your ass, I do. In a New York minute. And obviously, other doctors would as well, as Florida's highly publicized pill mill problem showed last year.
Florida's SB 668, and its companion bill in the house, HB 511, are a good step in the right direction, assuming they actually pass. They would limit the markup on these repackaged drugs, and effectively require they be sold at prices comparable to those found at a pharmacy. Similar efforts succeeded last year, only to be vetoed by outgoing Governor Charlie Crist. But it remains that the real solution here is a simpler, yet more extensive approach. Stop physician dispensing. Get the fox back out of the henhouse. Problem solved.