How I Choose your Medications: What you Should Know

Do you ever wonder why your doctor chose the medications they did?

Sometimes it’s during the medical visit.  Sometimes at the pharmacy counter (when you hear the medication cost).  Sometimes when watching a TV commercial.  But anyone who has received a medication from a provider has probably wondered this at least once.  And I’ve heard it all:  from Big Pharma conspiracy theories to drug rep lunches to a secret society where all doctors meet on their yachts (paid for by drug companies).

Isn’t it time you know what actually happens when I choose your medications?

A package of medications to show how a doctor picks medications
How I Choose your Allergy and Asthma Medications

What is the REAL reason your doctor chose the medications they did?

I recently had a patient ask me how I get samples of medications and then went off on a fairly entertaining (and somewhat alarming) monologue about how drug companies are paying doctors to use their product, and that doctors get kickbacks each time they prescribe certain drugs.

I cannot emphasize enough how untrue that is.

After talking with him, I realized he was trying to ask me why I chose the medications for him that I did.

 

This isn’t the first time I’ve heard this. In fact, I’ve had quite a few questions over the years about what drug reps do when they visit my office and what happens during drug rep lunches. So I’d like to answer this question for everyone who might be wondering the same thing.

Background history

As recently as 10 years ago, the assumption that drug companies paid doctors to use and prescribe certain drugs wouldn’t be entirely inaccurate.

There was a time when drug companies paid to take doctors and their families on lavish vacations, paid for golf trips and expensive dinners, and a lot of other things. I have heard stories in the past of doctors who would, in fact, prescribe only a certain medication in exchange for these gifts. I think culture this was even portrayed in the movie Love and Other Drugs.

Thankfully for the healthcare industry and you as a patient, those days are gone.  It’s no longer legal, nor is it acceptable, to financially influence what medications a doctor prescribes.  As a doctor, it’d be nice to be wined and dined and go on free vacations, but not at the risk of unethical prescribing.

Honestly, stories like these sound deplorable to me and weaken the doctor-patient relationship (which I very much value and want to protect). Congress and the FDA have also implemented increasingly strict laws and regulations to ensure these relationships will never happen again! You can rest assured, your doctor isn’t being paid or incentivized to prescribe you certain drugs.

I am very happy with the new rules and regulations.

I want my patients to know that I ALWAYS have their best interest at heart.

 

So what happens during drug rep lunches?

I wish that overall, medications would just cost less and there would be no need for samples and coupons to make medications affordable.

That would be ideal and is probably the “gold standard” for how modern medicine should be run. I will continue to support every bill and measure that comes up toward that end– to get my patients the medicines they need for the lowest cost.

The system right now, however, has medications costing astronomical amounts.  People can’t afford the straight cost of medications.  Coupons and samples make medications more accessible and affordable for the patient.

What do coupons and samples have to do with lunches?  It’s true that doctor’s offices are still visited by drug reps bearing lunch.  I welcome those lunch visits with open arms!

But, it’s not for the food/free lunch (in fact, I usually don’t even eat it because my wife sends me to work with leftovers–I leave it for the nurses and office staff). The real reason I welcome these lunches is that the reps use lunch as an excuse/nicety to visit the practice and educate about their product, but they ALSO bring coupons and samples for their products.  Coupons and samples that the doctor can then pass on to the patient who might need that specific medication.

These coupons and samples are especially prevalent in the world of allergy and asthma.  Many allergists will send you away with a sample of a medication they think will work for you, or a coupon.  Those samples and coupons are provided to the doctor via drug rep visits.

For some people, these savings can be upwards of $150+/month if a coupon is used! If a drug company wants to bring in some sandwiches with coupons to pass savings on to my patients, then I am happy to have them visit the clinic.

Obviously, just as with any other product sample/coupon, when I accept these samples and coupons each drug rep hopes that I will pick their medication to use over a competitor with a similar medication.

As a board-certified doctor, I am up to date on just about every allergy and asthma study/publication, every medication indication and every pro and con of each medication as they are released (click here to see an example of my approach).

I have done all my due diligence, so I feel comfortable that I can pick the best medication for my patients based on the current evidence. If I have a sample of that medication to give my patient, then I give it to them, but it in no way influences what medication I choose.  It’s just a side benefit if I have one on hand. So I allow any and all drug reps to visit and leave samples and coupons, in hopes that when I prescribe something, I’ll happen to have a freebie of that medication to give to the patient.  The greater variety of samples I have on hand, the better, because I prescribe based on what is best for the patient, not who brings in taco salad.

I hope that other providers are doing the same.

Who REALLY decides what medication you get?

What many people don’t realize is that the INSURANCE COMPANIES truly have the greatest influence on what products I can or cannot use for a patient!

Most of you recognize how complicated different medical plans are, but prescription coverage is even worse! Your prescription benefits are the single biggest factor in determining what medications I can or cannot use in your treatment.

If I wanted to treat you with medication A, but your insurance only covers medication B, then you’re going to get medication B (provided the benefit is the same)! I try to match up the best medication for your symptoms with what you’ll be able to afford based on your insurance.

However, the way drug companies influence insurance companies is a lot less straightforward, and can be downright sneaky

First, I know that drug companies and insurance companies negotiate for what medications are covered. I would LOVE to see this process more regulated,  open and transparent.  I don’t know what happens during these meetings, but I know that there seem to be a lot of changes occurring all the time with prescription drug coverage, and my patients seem to get caught in the middle.

Second, when an insurance company offers “all medications” they usually put their preferred medication at a lower tier and then their non-preferred medications at a higher tier.  From their perspective, I can technically give you any medicine I want… but YOU will be paying a lot more for a medication that they don’t “prefer.”

Third, if I pick a medication that is not on the lower tier, my office gets daily paperwork “advising” me to choose a lower tier or to “prove” my reason for prescribing a higher tier (a process which is so convoluted and complicated it often takes >1hr PER PRESCRIPTION to accomplish)

  • Parts of this I’m OK with, actually:
    • This tends to limit picking “the newest” medicine just because it’s new
    • It also helps prevent doctors from being influenced by drug rep companies
  • BUT it also takes the decision away from doctors… which isn’t always the best choice for the patient

 

So… how do I pick the medications I do for my patients?

I try to pick my medications with every patient’s best interest at heart. I typically go through a process similar to this with my patients:

  1. I always follow the FDA guidelines and don’t prescribe anything off-label.
  2. If the medicine is a short term or a trial medicine, I try to give a sample first to prove it works.
  3. I choose based on the class of the drug and not the individual drug (meaning I consider all medications that work for your needs and not based on a name brand).
  4. I also strictly follow the national guidelines and practice parameters, when available.
  5. When I have to give a prescription, I look up the lowest tier medication that will work for your symptoms and prescribe that first
    • If there are coupons or savings, I will give them to my patients at this time.
    • If the lower tier medication doesn’t work or causes adverse effects, I write a letter to get approval for a different medication.
  6. Finally, I tell my patients why I am choosing the particular medication, what medical and cost factors I used to make this decision, and review the decision with each person. I want each of my patients to play an active role in their own health by understanding how their medications are chosen!

So that’s it. I’m sorry I wasn’t able to confirm any conspiracy theory. In many ways, some of the conspiracies make more sense than the actual workings of the insurance system.

At the end of the day, at least in my practice, I’m just a doctor trying very hard to make my patients feel better at the lowest possible cost to them.

I hope that all doctors are striving for the same thing.


Next Steps

This is a pretty controversial topic for a lot of people. Share your thoughts, your stories about doctors AND your stories about prescription drug companies/insurance companies below.
The first step to changing this is to hear everyone else’s stories.

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