Managed Care:
Case 1 Discussion
Managed care plans often look to prescription benefits as a way to cut their costs. One common mechanism is formulary restrictions and co-pays on prescription medications. In this case, one initial question is whether the generic equivalent has the same clinical effectiveness as the name brand. When cost can be reduced without sacrificing clinical benefit, the ethical conflict is greatly diminished. If this is the case, Mrs. Jones should be reassured that the generic medication should be just as effective as the name brand.
Another issue is whether the patient should be informed that the pharmacy benefit is restricted because of cost. Many physicians believe that costs should not enter into clinical decision making. In modern health care, however, it is inevitable that costs affect clinical decisions. Patient involvement in clinical decisions is an important ingredient for respecting patient autonomy and fostering trust between provider and patient (see also informed consent). Your discussion should involve an honest disclosure of factors involved in a clinical decision, including costs. Mrs. Jones might be told, "I've looked at the medical literature and consulted colleagues I respect, and found that the generic equivalent is just as good as the brand name. Your health plan wants to save money when it can, which is ok as long as it doesn't result in inferior treatment. I don't believe it will in this instance; if it did, I would appeal."
If on the other hand, your research reveals that the generic is not as effective as the name brand, your duty as a patient advocate would obligate you to take all reasonable steps to appeal the decision. Most health plans have appeal mechanisms that will overturn coverage criteria with fairly minimal physician effort. They maintain this stance to limit their potential liability and to foster good customer relations. While the phone calls and letters this often entails are certainly an inconvenience, the effort is an important part of patient advocacy in a managed care environment.
Return to Managed Care | Return to Case 1