Rx Perspective
Managed Care Meddling
We should be aware of the situations generic substitutions can create and take these steps to protect our patients.

Despite what we write on our prescription pads, it's common -- and usually legal -- for cost-conscious pharmacists, hospitals and health plans to substitute a generic medication. This isn't all bad because it may significantly reduce the cost to patients. However, it's frustrating and creates situations we need to be aware of. For example:

• Mrs. X comes in and complains that the new drops (from a refill of her prescription) are more irritating than in the past. Perhaps the generic substitution contains the same active ingredients as the brand, but different preservatives or other components.
• A patient calls wondering why the drops received have a different name than what was prescribed and what should be done about it.
• A pre-op patient's eye drops are different from what was ordered.
• A managed care entity writes to your patient that it wants to use a different drop. This can cause the patient to doubt your judgment.
• The substituted bottle is different, perhaps harder to squeeze or releasing more than one drop at a time.
• The worst situation is when the substitution is thought to be a generic equivalent, but is completely different.

WHAT CAN WE DO?

We obviously don't have much leeway in these situations, but we can take these steps to protect our patients:

• Know the formularies. Our contracts with managed care entities and other healthcare plans stipulate that we adhere to their formularies, so we should know what's on each. When those medications are adequate, prescribing others wastes time. The company usually writes to us, requiring that we spend time on extra tasks, such as reviewing the record.

• 

  Know costs. We also should be aware of what medications cost and use the least expensive indicated medication that accomplishes our goal. To assess prices, I periodically send a list of my commonly used medications to several local pharmacies. Then I review my prescribing habits to determine what will be best for my patients. I also stay aware of the costs of generics and use them when possible. Strangely, it's not unusual for a generic medication to cost the same or more than a brand name.
• Spot check. To make sure patients are receiving the correct medications, I periodically ask them to bring their bottles to the office with them. I also have staff members verify that the medications listed in the patients' charts are indeed the ones I've prescribed or acceptable generic equivalents. It's common for staff members to carry over the medication list from previous notes, only to discover when questioning patients that they've actually been using something other than what's recorded.
• Educate patients. We should inform patients that a generic substitution might occur and that this would be OK. This decreases the number of phone calls from patients and relieves their anxiety. They appreciate our concern.
• Make preferences known. When I feel that a specific brand is the best medication, I write "dispense as written" on the prescription. This usually requires a phone call to the hospital or managed care plan as well. We can also set up a form with some "fill-in space" that we can fax to the approval agency. It's rare that such a request wouldn't be honored.

WORKING AROUND THE REALITIES

We resent these intrusions on our judgment, but they reflect current medical care limits. We shouldn't penalize patients by not making the extra effort on their behalf. 

Dr. Weinstock practices at Canton Ophthalmology Associates in Canton, Ohio. He's also a professor of ophthalmology at the Northeastern Ohio Universities College of Medicine in Canton.