In Support of Health Care Reform

After reading your February, March, and April editorials, I would like to share the following thoughts concerning health care reform from the perspective of a pharmacist practicing for 32 years.

• Health care reform in the United States is a must. It must be undertaken now! We missed our chance for reform in the 1990s, when Congress did not pick up Hillary Clinton’s plan and rework it to make it acceptable. We spend more on health care per capita than any other nation and have less to show for the money spent. Quality, affordable health care must be achieved for all citizens in the United States. I do not believe health care should be an entitlement program, but we do need standardization of health insurance. I support consolidation of health care policies available into not more than 3 types. These would be portable and allow for providers and patients to have a thorough knowledge of the coverage available. Basically, these would be government-mandated policies. The private sector would still offer the policies, and the public would be able to choose providers based on service and cost.

• Yes, use of electronic health records needs to be scrutinized closely. This process will not come about easily. Pharmacists’ ability to move information electronically is far ahead of other health care providers’ ability. We have regularly used computerization in practice for well over 20 years, although we still do not have everything right. Part of our problem is lack of standardization of the various programs. While I am not for “big government,” it may take a government-based system to be able to easily integrate all the disciplines of health care under one umbrella.

• Meanwhile, the federal government and MCOs need to realize that health care providers, physicians, hospitals, pharmacies, etc, are not lending institutions. We are in business and need to be paid in a prompt manner. For pharmacies, the average turnaround time for payment is about 30 days, while more than 90 days is common for other health care providers. With electronic submission of claims by pharmacies, turnaround time should be about 48 hours-the standard set by the banking industry. Pharmacists processing claims in real time know at the point of service if a patient is eligible, if the claim is paid, and what the reimbursement will be. The PBM industry says it needs assurance of “clean claims” to justify the 30-day payment window. If it is not a clean claim, it should be rejected at the point of service. Processing in real time for all health care providers should be a reality.

• PBMs need to rethink the prior authorization (PA) and step-therapy processes. Recently, we had an outbreak of GI “flu” in our small community and 1 long-term– care facility was hit especially hard. Physicians were prescribing a short course of ondansetron tablets for the nausea and vomiting, for which PA was needed. After spending an hour on the phone, I was able to get only 1 of 3 patients approved for treatment with generic ondansetron. Considering the time spent by the PBM customer service representatives, the PBM would have been better off covering these short courses of ondansetron. The same applies for terbinafine tablets. Implementing PA for these inexpensive generics must actually cost the PBM money. I have not mentioned the time spent by physicians and pharmacists.

• I disagree with the statement that controlling the costs of brand-name pharmaceuticals would decrease drug innovation. There are few truly American pharmaceutical manufacturers left. Much of the initial research done on pharmaceuticals is supported by tax dollars through the NIH and public colleges and universities. In many cases, pharmaceutical manufacturers purchase the rights to promising compounds and conduct clinical trials. Why should the citizens of the United States be expected to pay for drug research that benefits every other country? With no brand-name price controls, the US market becomes a “cash cow” for the global pharmaceutical industry.

• Pharmaceutical manufacturers are becoming more transparent, but they still have a long way to go. They have realized that the physicians no longer drive their sales exclusively. Doing away with the practice of giving out promotional products, pens, pads, trips, T-shirts, golf balls, etc, labeled with their company’s or drug’s name is long overdue. However, I do not believe that I have seen that companies are decreasing promotions to PBMs or MCOs and their employees-the “new” audiences to sell their products to.