When Pay for Performance and $4.00 Generic Prescriptions Hit the Wall

This is something in my conversations with physicians that keeps coming up, so I thought I would write up a post.  On this blog I provide links to the $4.00 and other cost saving areas for anyone, insurance or no insurance to find the best cost on generic drugs and these are the heaviest hit links on the site at all times. 

On the back side of this is an area for physicians called "Pay for Performance" with HMO carriers, so how do these 2 relate?  That's a darn good question, but they do.  Income and/or bonuses for how a physician is doing his/her job are based on a set of criteria and one of which is "is the patient taking their medication", in other words they look at how effective a physician is with prescribing methods, and the 2nd issue that comes up in the evaluation process is "are they writing enough generic prescriptions", in other words it is a cost item and it is evaluated to make sure there is a mix and that everything is not a name brand prescription.  There are many instances though when a generic drug is not available, and guess what the pharmaceutical companies focus on?  Ok, now that one was not too hard to guess.

Ok, the next part of the scenario, how do the HMO agencies know who is filling their prescriptions?  Well that is pretty easily done when you show your card at the pharmacy to fill your prescription, it all gets tracked, so the HMO knows if you filled your prescription and tallies all those results when they review their participating physician members.  Everything is pretty much in a data base today, and of course the medication goes into your file at the insurance/HMO level. 

So if you don't fill it, it appears you are not following doctor's orders, and then the Spanish Inquisition starts for the physician as far as "why are these patients not taking their medications" when it comes time for pay for performance, in other words these reports generate query and come up with the numbers.  I have heard this a number of times from many so it is a very common practice.  Also, in the process they look at the number of name brands versus generics and there are goals and criteria associated there as well.

Here's the next part of the scenario, if you take advantage of the $4.00 generic cash prescriptions, you don't need to show any insurance card, etc. because at the low price, we are not worrying about a $5.00 to 25.00 co pay by any means, so this means that it is not tracked through the normal routes, and if the physician has a large enough number of patients who take advantage of the low cost drugs (which can mean the difference of whether or not a patient can afford their medications) on paper or in data reports, all of a sudden the physician looks like he has a whole bunch of patients who don't bother to take their medications, when in fact, the prudent patient is taking their medications and saving money, so in reports they can be perceived somewhat ineffective, nice huh? 

Now this is a sad state of affairs to be the prudent consumer, and yet you are potentially taking money out of your doctor's pocket by doing so when it comes to pay for performance for them, so what's up with this? 

Doesn't this make you feel bad?  Of course it doesn't and most physicians just want to make sure you are taking care of your health and deal with the evaluations from the HMO and explain the same thing over and over, while other physicians basically tell them to mind their own business as there is nobody but the patient in control here.  Those with electronic records and a registry reporting format can simply facilitate a few clicks and create a report for rebuttal purposes, but those on paper patient records have a much more time tedious task to substantiate. 

Not a real good system for the physicians and yes it's a question they answer all the time when it comes to their compensation from the HMO.  Being the prescriptions are cash and not recorded with the insurance companies at the bargain retailers, this can also in some way be viewed as a positive as it is one less item in your file relative to let's say chronic health care, so why does that make a difference?  All insurance carriers compare notes through the MIB, (medical insurance bureau, not men in black) and the qualification process for insurance these days is taking in to effect what drugs you are taking, so in other words if they look at your Pharma rap sheet, well you get the drift here.  The use of the MIB for insurers is up 14% this year. 

The same holds true for cash office visits, nothing gets reported for what you pay cash for, so something to be said for cash.  For more than one reason, doctors like cash too.  It is difficult for a physician today to go to a concierge practice as the carriers can be quick to cancel their contracts. 

Now some retailers are getting a bit more savvy about the situation and want you to join their club so you can get a generic prescription at the discounted rate, so this will look better for the doctor as now it can be tracked and reported through the "club" data base and you look like a star in taking your medications, and if you have other prescriptions through you health plan that you do pay a normal co-pay for it is identified and all tied together, so once again there is a data trail in place.

Now some companies like Aetna have a lottery pilot program going, that's right you heard that, take your pills and hit the lotto, well a small lotto that is.  Almost reminds me of some of the reality shows today, "pill or no pill".  I think if we are health conscious and can afford our medications, as patients we will take our pills without having it turned into a mockery of whether or not we take our pills.  The electronic device will also tell you how much you could have won if you had taken your pills for the day. I would hate to see this graduate to Pay for Performance for the physician based on how may patients hit the lotto with the number of pills taken, but if you were a sick physician taking a prescribed medication you could double your odds. (grin). 

  "1-in-10 chance of winning $10 every day they take their medication and a 1-in-100 chance of winning $100. Each day a text message will tell a subject whether he or she has won the lottery, or, if the dose wasn't taken, whether he or she would have won."

There is also a big move on for medical tourism and a couple of the major insurance companies are speaking at this year's annual meeting, and who knows it might be a physician/patient relationship someday together to broker your procedures as well, but I hope not as the process just complicates healthcare and inconveniences all. 

Employers just threatening to send employees overseas for care has prompted some domestic hospitals to step up with offers to match the foreign prices.

I don't know how much this accomplishes though as so many are having financial issues already. 

So just remember the next time you get that $4.00 prescription, how the system works and keep doing what is best for you and following doctor's orders.  

Seriously who would not take advantage of the pricing, I do. 

Perhaps the Pay for Performance for physicians in this area can be re-evaluated soon as it doesn't seem to be making a whole lot of sense for anyone and the insurance industry is wracking their heads on how to get it documented at almost any cost or limit.  BD

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