Not What the Doctor Ordered

Restrictive formularies tie ophthalmologists’ hands and impact patient care.

BY Jerry Helzner, Senior Editor

A new and compelling study reveals a major disconnect between the way many managed-care plans select their ophthalmic drug formularies and the drugs ophthalmologists would prefer to use.

The 40-page study, called The Eye Care Trend Report 2013, was conducted by Kikaku America International, a pharmaceutical consultancy. It includes interviews with 63 ophthalmologists, 63 optometrists and 89 administrators at managed-care organizations (MCOs) conducted in late 2011 and early 2012. An independent editorial advisory panel analyzed the responses. Ophthalmology Management was provided with an advance copy of the report.

This article will explore those aspects of the report that are of greatest concern to ophthalmologists and look at how MCOs come up with the formularies that are so frustrating to doctors.

What Most Concerns Ophthalmologists

From an ophthalmologist’s perspective, the study starkly highlights two of their major concerns. First, MCOs are often quick to mandate pharmacies substitute generics for branded products, even though ophthalmologists find that generics sometimes fail to meet the effectiveness of the branded products they are meant to replace (Figure 1).

Figure 1: How MCOs Enforce Generic Prescribing

In addition, 70% of the ophthalmologists who participated in this study say that a patient’s ability to adhere to a specific therapy strongly influences their prescribing decisions. With limited formulary choices, ophthalmologists may sometimes be unable to prescribe the therapy (such as a combination glaucoma medication) that best meets the individual patient’s needs.

“Patients control their own destiny,” said one ophthalmologist interviewed for the study. But he says they can only do so when ophthalmologists are free to educate patients on the importance of adherence and choose therapy regimens that can be matched to the personalities and adherence capabilities of individual patients.

MCOs: Ophthalmic Drugs Not a Priority

Probably the most stunning finding of the study is that the vast majority of managed-care respondents do not consider the development of drug formularies for ophthalmology a priority. Only 11% of the plan administrators surveyed said they pay much attention to eye care at all (Figure 2, page 22), and 20% saw the category as becoming more important in the future as more than 75 million baby boomers reach an age when eye problems become more prevalent. However, more MCO administrators said they would pay less attention to eye care in the future than today.

In their defense, MCO administrators cite two primary reasons for the current lack of attention to eye-care drug formularies. “The feeling here is that there just isn’t a lot of prescribing abuse among these specialists,” says George Hiller, RPh, pharmacy benefits consultant at Hiller Pharmacy Management Group, Birmingham, Ala.

The other reason for the low priority of eye-care formularies is that commercial insurers tend to see the more expensive therapeutics, such as the anti-VEGF drugs used to treat retinal disease, as being more of an issue to Medicare with its seniors-only population. “Macular degeneration is certainly more of a concern to the Medicare population,” says Randy Vogenberg, RPh, PhD, co-founder of Bentelligence and a principal at the Institute for Integrated Healthcare.

However, MCOs with large Medicare populations tend to spend more time developing guidelines for retina disease coverage. “Plans that want to stay competitive in attracting Medicare beneficiaries need to stay on top of emerging ophthalmologic therapies and guidelines,” Mr. Vogenberg says.

This should also include more screening of people with diabetes for diabetic retinopathy, say administrators of forward-looking MCOs.

“Physicians traditionally haven’t been reimbursed for screening or other prevention and wellness services, but with plans investing more in wellness and prevention, things are going to start changing,” Mr. Hiller notes.

The Disconnect On Generics

With little attention paid to developing the specific drug formularies that ophthalmologists would prefer, MCOs tend to freely substitute generics for branded drugs despite doctors concerns that generics often do not provide equivalence to branded drugs in safety and efficacy. In addition, plans often fail to include combination glaucoma drugs in their formularies, although combination drops can offer convenience, lower overall drug costs and more effective treatment to patients.

To measure the level of the disconnect between plans and ophthalmologists over the equivalence of generic drugs, the study asked respondents to give a value of 1 to 5 (with 5 meaning no difference between generics and branded products) as to whether generics were fully equivalent to branded drugs. The managed-care respondents averaged 4.5 in their evaluation of equivalence while ophthalmologists averaged 2.4. In terms of whether nonactive ingredients in eyedrops could make a difference in a drug’s efficacy and tolerability, managed-care respondents averaged a rating of 3.6 in favor of “no difference” while ophthalmologists averaged a rating of 1.7 in favor of “major difference.”

Despite ophthalmologists’ distrust of generics, some ophthalmologists say the profession has tended to be passive in accepting them because the substitutes offer low cost and what one ophthalmologist describes as “generally good value” to patients. However, the results of this study indicated ophthalmologists want more say on the issue of generics and may not be as accepting of them in the future.

Doctors Want Choices

Clearly, MCOs are far less concerned about substituting less costly generics in their formularies than the ophthalmologists who often find a lack of equivalence in generics.

Figure 2: MCOs’ Eye Care Attention Deflcit

Ophthalmologists who participated in the survey strongly believed (average rating 4.0) that they were best suited to determine whether a brand or generic drug was the appropriate choice for a specific patient. Managed-care respondents tended to disagree, giving doctors’ choice an average rating of only 2.8.

“How can reviewers judge a treatment’s appropriateness without reviewing all the records behind a prescriber’s decision?” asks ophthalmologist L. Jay Katz, MD, director of the glaucoma service at Wills Eye Institute, Philadelphia. He believes only peers should review a prescriber’s decision to choose a specific medication.

Figure 3: Eye Care Representation on Formulary Boards

Plans Setting a Low Bar?

What the chasm between MCOs and ophthalmologists over the use of generics indicates is that many plans tend to develop their ophthalmic formularies in an almost casual manner. The plans’ pharmacy and therapeutics committees often rely on just one consultant or a few ophthalmologists to develop a formulary of ophthalmic drugs (Figure 3). Sixty percent of managed-care respondents said that the availability of a generic was a major consideration in deciding what drugs to put on the formulary, while 43% cited cost as a factor. However, the managed-care respondents said safety, efficacy and assuring best practices were more important than cost in choosing a drug for the formulary.

The drug formularies MCOs create have a real impact on the every-day practice of ophthalmology. “Formulary restrictions have a big effect on what ophthalmologists prescribe,” says Michael Raizman, MD, of Ophthalmic Consultants of Boston. Dr. Raizman notes that some newer, more effective fluoroquinolones indicated for perioperative antibiotic treatment are not used as much as they could be “because they typically aren’t covered by health plans.”

Besides antibiotics, other drug groups in which ophthalmologists often encounter formulary restrictions are glaucoma agents, steroids and treatments for conjunctivitis. Overall, a whopping 92% of ophthalmologists said that either all or a majority of commercial insurers place formulary restrictions on ocular products. In evaluating formularies Medicare carriers impose, 75% of the ophthalmologists interviewed said they encountered limitations, particularly with glaucoma treatments.

Figure 4: Doctors’ Opinions on e-prescribing and Patient Care

Limitations on formularies do not sit well with busy ophthalmologists.

“We’ve got enough work to do without having to argue with insurance companies about whether the patient can get the medication we prescribed,” says Robert C. Campbell, MD, of Parkwood Eye Center, Elkin, N.C.

How to Bridge the Gap

Because most MCOs are not putting a priority on selecting their ophthalmic formularies, the study suggested they could better meet the needs and wants of ophthalmologists and patients if they took into account such factors as practice guidelines, articles in peer-reviewed journals, evidence-based medical studies, comparative-effectiveness studies, views of key opinion leaders, product package inserts and other available resources. Doctors and MCOs also view greater adoption of e-prescribing as a step in the right direction (“E-prescribing Shows Promise,” at right).

Ophthalmologists also told the study’s interviewers that MCOs and doctors could do more to promote the all-important element of patient adherence if the health-care plans would share their adherence data with physicians. About 70% of ophthalmologists said they currently do not receive adherence data from the plans with which they contract.

Taken as a whole, the study should serve as a red flag to spur cooperation between MCOs and ophthalmologists to work together in the future to develop ophthalmic drug formularies acceptable to MCOs but that also meet the real-world needs of doctors and their patients.