Barriers to access attributed to formulary changes

Health insurers change their formularies to increase medical effectiveness and save money, and a new study from Case Western Reserve University has determined the effect these changes might have on patient care with respect to the prevalence of difficulty in filling a prescription and resultant problems.

Questionnaires were mailed to 1,200 patients who had visited any of three family medicine practices within the previous six months, asking them to describe problems that they encountered when filling prescriptions.

Mark N. Rood, MD, of the department of medicine at Case Western, and colleagues found that 23 percent of patients reported missing doses of their medication because of difficulties related to insurance, and 8 percent reported a worsening of their medical condition.

Of the 100 patients reporting a problem with a medication, 21 percent had a problem with a new prescription, 42 percent with a medication they were already taking, and 37 percent with both.

It is suggested that clinical executives are not adequately taking into account the true costs to the patient population when they make formulary changes. The researchers found that vulnerable populations — particularly people on Medicare and/or Medicaid — bore a disproportionate share of the consequences of formulary changes.

Rood says, “Establishing universal best-practice guidelines for evaluating the clinical and cost effectiveness of one agent over another would go a long way toward ensuring that a significant threshold is met before formularies are altered.”

The study recommends minimizing variation among insurance company formularies instead of the existing practice of each insurance carrier using its own pharmacy committee to develop a drug list.

“If a drug is judged by evidence-based best practices to be of high quality and cost effectiveness for one insurer, it is reasonable to conclude it should be the same for all,” Rood says.

“Our study found that although patients were less likely to blame their physician than their insurance company or pharmacist, physicians bore the [greatest] administrative burden for fixing the problem.”

n=100

Patients reported, on average, 2.9 problems.

Source: Rood MN, Cruz-Knight WC, Cunagin J, Zyzanski SJ, et al. The effect of insurance-driven medication changes on patient behavior. swJ Fam Pract. 2012;61(7):E1–E7