AJMC Editorial Making Waves in Managed Care

Since it appeared last week, the editorial in the September issue of The American Journal of Managed Care, “Is All ‘Skin the Game’ Fair Game? The Problem With ‘Non-Preferred’ Generics,” has received comment in The New York Times, ProPublica, US News and World Report, and Mother Jones, among others. Commentators note that what Gerry Oster, PhD, and Co-Editor-in-Chief, A. Mark Fendrick, MD, uncovered in their brief survey of health plans is not just disturbing but possibly violates the Affordable Care Act’s prohibition against discrimination based on pre-existing conditions.

Drs Oster and Fendrick found that plans are not only splitting generic drugs into preferred and non-preferred tiers, but they are also leaving some conditions with no “preferred” generic at all. At least some of these decisions appear to be based on price alone, not on science. As Drs Oster and Fendrick note, if the point of patient co-payments — the so-called “skin in the game” — is to encourage more judicious consumer behavior, what’s the message to the patient with no low-cost option?

Commentators have been quick to pick up on that argument. Managed care, these voices note, is supposed to find savings through efficiency, not refuse care outright. And Oster and Fendrick write that by creating “non-preferred” tiers for a host of commonly prescribed generic drugs, some plans have, de facto, done just that. They found patients affected by such policies include migraine sufferers, persons with HIV, and those with mental illnesses. The authors ask: are the drugs “non-preferred,” or the conditions themselves?

Their example of metformin is especially instructive in light of the discussion Monday in Orlando, Florida, at the US Psychiatric and Mental Health Congress. Joseph P. McEvoy, MD, of the Medical College of Georgia, called upon his fellow psychiatrists to become competent in treating basic cases of diabetes and hypertension for patients with serious mental illnesses who were unable or unwilling to get care from a primary care physician. Dr McEvoy lauded metformin’s benefits in particular, as this drug does not cause weight gain and may even produce some weight loss — something particularly attractive for those on certain antipsychotic drugs. But Drs Oster and Fendrick found that benefit, and the fact that metformin has long been the most basic, first-line therapy for the treatment of type 2 diabetes, did not prevent the drug from being booted to the “non-preferred” list for one plan.

ProPublica had already reported on complaints filed by 2 Florida advocacy groups on prescription drug pricing discrimination. It remains to be seen whether more groups will join the fray.

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