EDs look for middle ground on formulary changes
More hospitals are moving to closed formularies, with increasing attention paid to prescriptions for drugs commonly used in the ED
Hospital formularies are inching closer to shutting the door on disgruntled emergency physicians over the question of who is the final arbiter of medication orders: the attending physician or the formulary?
In an effort to better control the cost of medications that are ordered for patients, formularies have been moving cautiously toward placing ever tighter controls on expensive drugs. Now, they’re widening the net to a greater degree on commonly prescribed medications such as antibiotics and analgesics.
The controls are forcing emergency physicians more than ever into making tougher choices between expensive, hospital-restricted medications and cheaper, often less-effective substitutes.
Formularies often quibble over cost
"The effects are subtle, but they’re forcing all of us into making daily economic decisions about common medications like antibiotics," says Wesley Fields, MD, associate medical director of the ED at Saddleback Memorial Medical Center in Laguna Hills, CA.
Sometimes the cost difference is miniscule. But, collectively, EDs are regarded as big users of commonly-prescribed medications, says Laurie P. Forrester, PharmD, vice president of clinical services with Pharmerica, a Dallas, TX-based company that operates hospital and nursing home-based pharmacies.
It’s "the age-old battle between the forces of managed care and the advocates of clinical independence," Forrester says.
Whereas, in the past, the focus lay on critical, high-cost drugs like thrombolytics for cardiac patients, the front has shifted to more common, everyday medications such as erythromycin and other cephalosporins, Fields says.
And that’s where the focus is likely to stay for a while as hospitals move from relatively open formularies toward more closed, restrictive ones, says Forrester.
The aim isn’t so much to effect a sudden, sharp drop in costs but "to help move physicians slowly into so-called preferred agent lists’," Forrester says. The initial targets of controls are pain killers, antibiotics, and anesthetic agents, she adds.
Until recently, strict formularies have not been the norm at most hospitals. Except for teaching institutions, where the emphasis is on using specific medications in clinical education, less restrictive, open formularies have generally been the rule.
Fierce competition is fueling controls
But market forces are fueling a change. Managed care organizations have been stung in recent years by fierce competition among themselves and higher overall clinical outlays. In turn, they’ve put pressure on providers to cut costs even in the ED, where medication expenses typically represent less than 10% of managed care expenditures.
Large employers and pharmaceutical manufacturers have been squeezing MCOs for better prices, while pharmacy benefits and drug costs have escalated sharply due to competition.
Hospitals themselves are clamping down on physicians’ drug decisions in response to growing capitation and fixed, global payments that leave little room for expensive, high-volume orders.
According to the American Society of Consultant Pharmacists in Alexandria, VA, open formularies have, to some degree, allowed physicians broader scope and freedom in ordering patient medications based on their own preference and experience.
"Under closed formularies, certain drugs are on the prescribed list and others are simply not available," Forrester says. Physicians are limited to using only those on the list.
Hospitals are choosing closed systems
Closed formularies also eliminate or severely restrict the use of certain drugs for the following reasons:
• the drug is effective but perceived by either the MCO or the hospital’s pharmacy committee as having off-setting risks or negative side-effects such as intolerance or digestive reactions.
• the drug is the therapeutic equivalent of another less-expensive or more convenient drug for patients such as zithromax compared with erythromycin for acute upper respiratory ailments.
• the drug is a highly specialized and high-cost therapy, such as the blood-clot buster TPA, which is used on special patients and only by certain specialists.
Hospitals are steadily moving away from the open, flexible formulary to the more closed format, Forrester reports.
But, physicians acknowledge that formularies can be helpful in pointing out useful, effective medications that are often as good, if not better than, their more high-priced equivalents.
"Some cheaper, second-generation antibiotics have a broader spectrum of uses and ironically turn out to be less germ-resistant than what many physicians have originally preferred," says Louis Graff, MD, associate director of the ED at New Britain (CT) Hospital.
"Many second-generation drugs, such as certain penicillins, are actually doing something good," Graff adds.
Nevertheless, practice guidelines, not hospital economics, should be the priority for practitioners, says Fields of Saddleback Memorial.
Physicians ponder ethical questions
There are other implications for emergency physicians underlying the formulary issue.
For example, if clinical independence is important to you, the hospital’s pharmacy and therapeutics committee should be the forum for taking a stand, recommends Graff. "Get involved in the committee process," he advises, "Hospitals should be urged to put more physicians on these committees," he adds.
Also, can you ethically ensure consistency with all of your patients on your medication orders? "Almost 40% of walk-in ED patients are uninsured. Can you continue to write orders for the same medications without reasonably accounting for the unreimbursible nature of these uninsured visits?," Graff says.
However, counters Fields, a decision to accept the formulary’s policies may reverse everyone’s best intentions. The consequences of cheaper, less effective medications may come down to higher incidents of negative outcomes, high recidivism rates, and return visits, says Fields.
"The issue makes us all wonder at times, if there were no MCOs controlling patient-care would there be such worrisome incidents of reported patient complications?" he muses.
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