Patients, Payers, and Plans Vexed by Formulary Problems

We usually leave concern about consumers to consumer publications. At least that's the official position. Many times at story planning meetings, we've killed ideas when we started to say something like, “This is a shame for the poor patients who. . . .” You can fill in the blanks with such phrases as “who can't go out of network to the physician of their choice” or “who can't make sense of the options offered by consumer-directed health care” or “who don't have easy access to their medical records.”

They — consumers, patients, employees (much overlap here) — are not our readers and we do not care about them, we joke. Except that we do, and we know that you do too. We care because, first, we are a subset of them and, second, nearly everyone we know falls into that class. Then, on a professional level, we care because what happens to them does affect our readers at health plans and provider organizations. Still, we usually manage to keep sentiment in the background. We're all business.

That's why this month's cover photo is a departure. The woman, a patient, is in not just in physical pain. She's confused by formulary restrictions and, when copayments are high (as they can be for some of the newer pharmaceuticals and biologicals), in financial pain. And this is not counting her physical pain.

Our cover story presents a business problem with a human face. Is your formulary optimal? Or does it have obstructive elements? The human toll is obvious. The business toll is also easy to see.

Now, for solutions. These are harder to come by, but we think the article's author, Contributing Editor John Carroll, reports on some effective approaches that are being tried in various parts of the country. Heaven knows, it's a vexing, complex problem.