All stakeholders within the pharmaceutical supply, distribution,
and consumption chain have their own agenda. The stakeholders
—patients, health professionals, plan sponsors, pharmaceutical
companies, and governments—may learn from each other’s point
of view. What would Pharmatopia, the fictional land where the
drug system favors the inhabitants, look like from the perspective
of each constituent?
Pharmaceutical manufacturers in Pharmatopia see all research
results in salable compounds. The FDA approves all compounds.
Patents do not expire. Physicians write prescriptions for brandname
drugs only. No restrictions are placed on advertising to consumers
or physicians. There are no formularies. Plan sponsors do
not restrict access to any drug or class.
The FDA in Pharmatopia finds that all drugs are safe, effective,
and can be used over-the-counter. Manufacturers make no unsubstantiated
claims. Congress does not second-guess FDA rulings.
From the prescribers’ view of Pharmatopia, all drugs work. No
drug has a side effect or harmful interaction. Any drug on the market
is appropriate for all patients and may be used without restriction.
Patients do not ask for specific drugs when they visit.
Pharmacists need not call for prior authorizations or formulary
For patients in Pharmatopia, all drugs are accessible without
restriction or copayment. All drugs work and have no side effects
or harmful interactions. Their employers have plenty of money
after paying for health care and offer large, annual raises.
For pharmacists in Pharmatopia, physicians write legibly or
submit all prescriptions electronically. There are no drug shortages
or recalls. All drugs are available generically. There is no shortage
of pharmacists. Dispensing fees are adequate, and prescription volume
allows time for extensive patient counseling.
Pharmatopia for plan sponsors (state, federal, and private
employers) is quite intricately woven. The FDA is shut down so
that no new blockbuster drugs make it to market. All members
from the CEO/governor/president on down are on a single drugbenefit
plan. Members take only the medications that they need to
maintain their health and insist on having premiums and copayments.
Members with chronic problems take the medications
needed to maintain health and avoid deterioration.
Pharmacy Benefit Managers (PBMs) and other providers of
pharmaceutical care have an ambitious view of Pharmatopia.
citizens work and have a pharmacy benefit. Pharmaceutical spend
trend can be managed to the negative side. Members understand
their pharmaceutical benefit and use it appropriately. All plan
sponsors appropriately implement every clinical program. All
claims adjudicate, resulting in no call volume. Pharmacists are satisfied
with their reimbursement. Pharmaceutical manufactures
offer large discounts without regard to volume.
The Congressional view of Pharmatopia includes the availability
of all drugs from Canada. The elderly use fewer drugs as they
age and use their savings to purchase the drugs that they consume.
Pharmatopia can be legislated. Everyone votes for the incumbent.
A Dose of Reality
The chemical and pharmacological properties of drugs are examples
of natural trade-offs: effects versus side effects. Within the
delivery system, one constituency’s Pharmatopia is another’s bane.
The system cannot simultaneously have only brand-name drugs
and only generics. New chemical entities are expensive to bring to
market and must support those that never become approved. The
FDA exists to protect citizens from ineffective or toxic substances
and unsubstantiated claims. Drug interactions play a major role in
Drug spend trend continues in double digits even with aggressive
management. Formularies continue to be used as a tool to
steer drug use to the safest, most cost-effective therapy and promote
rational therapeutics. Generic drugs lower the cost of drugs
to patients, health plans, and governments. Patients ask for drugs
that they see advertised whether or not they are appropriate.
Sponsors are unwilling to spend money on lifestyle drugs in order
to conserve resources for life-saving therapies.
If stakeholders receive some of the items from their personal
Pharmatopia and the system runs most efficiently, then Universal
Pharmatopia might take the following shape.
Drug companies keep doing research and enjoy, but don’t
abuse, the normal patent life. The FDA assures that safe and effective
medications reach the market in a timely manner and does not
compromise effective prescription drugs into ineffective OTCs by
halving dosages. Prescribers take the time to briefly explain why an
older drug really is best when patients ask for a particular brand.
Practitioners write prescriptions for generics whenever they have
the opportunity and embrace the technology that replaces the prescription
pad. Patients follow their physicians’ advice and use
generics or over-the-counter drugs when available. People get used
to paying a larger portion of their own medication expenses instead
of looking for someone else to pay for what they consume. Patients
resist incessant direct-to-consumer advertising of new drugs.
Pharmacists negotiate a fair reimbursement contract—and then
perform. Technology is adopted to streamline the entire drug delivery
system, especially at the point of service. Plan sponsors promote
or mandate generics and use quantity limits and prior authorization
judiciously. Other clinical programs are tried; success is rewarded.
PBMs and other providers of pharmaceutical care continue to offer
value in management of drugs to enhance the well-being of members.
The plans prosper and the providers share in the success. The
U.S. Congress does not buy into the reimportation scam for shortterm
benefit but reduces direct-to-consumer advertising. If a
Medicare prescription drug benefit is enacted, it is means-based
and does not produce undue burdens on future generations.
Drugs provide huge health and societal benefits when used
properly. The pharmaceutical supply chain must remain profitable
for the producers and affordable for consumers. While each constituency
brings its own needs and biases, the goal is to wring the
waste out of the system while assuring progress against the real villains
—disease and suffering.
A system of checks and balances in which everyone wins
something may be all that can be expected, but innovations may
still add to efficiencies and bring us all closer to Pharmatopia.------------------------------------
Steven M. Pepin, PharmD, BCPS Principal PHARMWORKS, LLC
Copyright Journal of Managed Care Pharmacy JMCP November/December 2002 Vol. 8, No. 6
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