How do doctors decide which drugs to recommend?

Choosing the right medication for a patient is a complex exercise. Many factors go into consideration and of course the patients' preferences are taken into account as well. One of the most common rheumatologic disorders I treat is rheumatoid arthritis, which is one of the more common types of autoimmune diseases in the US. When I see a patient in my office for a check up on their rheumatoid arthritis, the patient shares how he or she has been doing since the last time they were in. How are they sleeping? Are they missing days at work or at school? Have they had trouble taking care of family obligations? Has there been a change in the health plan's formulary or coverage? How long does their morning stiffness last? Are there any swollen joints? How bad is their pain? Are they experiencing any side effects? Is there a plan to have a child? We then talk about any other changes in their health or family. Next, I examine the patient's joints and determine how much activity I can see or feel. We also review their most recent blood tests and radiographs together.  

If my patient and I decide that a change in medications is warranted, the first step is to review previous medications that he or she has tried already and what didn't work about those medications. Next I go through the patient's health history to determine what other conditions he or she may be dealing with that would make a certain drug a poor choice. For example, a history of cancer, multiple sclerosis, high cholesterol, diverticulitis, retinal disease, liver disease, infections, low blood counts and others can all influence the choice of medication. Once I've narrowed down the list of drugs to those that are safe for my patient, we have a discussion about the patient's preferences. An infused drug may not be the best choice for a single mother working full time who can't come in to the infusion center for eight hours every six weeks. A patient with a severe fear of needles may prefer a medicine in pill form. A patient's friend or family member may have had a bad experience with a particular drug and they do not wish to try this drug. 

Once we've found the medication that is the best fit for my patient's health and preferences, the process moves toward the logistics of getting the medication into the hands of the patient. Unfortunately, I am unable to see how much a prescription will cost until I send the prescription to the pharmacy and the patient goes to fill it. This makes it very difficult to keep the cost of the medicine in mind when I am helping my patients make a decision that is best for them. Making this choice even harder, my patients have all different types of health insurance and I do not have access to each patients' individual plans and out of pocket costs. When the patient has a Medicare Part B plan, the pricing is a bit easier to anticipate if we choose an infused medication. Part B will cover 80% of these medicines and if the patient has a co-insurance the remaining 20% will be paid for by this coverage. Alternatively, injectable drugs are in a specialty tier, meaning that the patient isn't charged a co-pay but will pay for a percentage of the cost of the medicine. For example, the lowest cost injectable medicine for rheumatoid arthritis costs about $15,000 a year. The amount covered varies by prescription plan, but usually this would leave the patient with about a $5,000 yearly out of pocket cost for this drug only. I also need to take into consideration whether a Medicare patient is in the "donut hole", which may cause us to put off escalating therapy to a time when it is more economically feasible for the patient.  

 Fortunately my practice employs two coordinators to help us with prior authorizations. This step is especially cumbersome as each insurer has their own protocol for requesting medicine. As of now, there is not a universal prior authorization process - some require fax, some require US mail, some are electronic and most result in hours on the phone. The coordinators work behind the scenes after the clinic visit to fill out the proper forms and wait for a response from the health insurance company as to whether my patient will get his or her first choice in medications. Sometimes the request will be approved right away, but more often the case is the health insurance will make the patient try a drug that is less than ideal for that particular patient first. This is called "step therapy". For example, it is the policy of some health insurers that every patient with rheumatoid arthritis has to try Drug Z and Drug R before being able to try Drug H or Drug L. The purpose of step therapy is to encourage use of cheaper generic drugs before trying more expensive drugs. In the world of rheumatology, there are no generic drugs that we can use instead of disease modifying therapy or biologic drugs. 

Usually after a few days to a few weeks of back and forth paperwork, the decision will come from the insurance company to approve a drug for the patient. The next step is to call the patient and tell him or her what their cost for the medicines will be. Sometimes the patient can afford the co-pay, but there are many instances where the patient cannot afford their out of pocket portion. The process will then start again to try for a different drug which may have a lower out of pocket cost. The other option is to apply for assistance programs for help financially. Co-pay coupon cards can help to make the medicines more affordable as well, but patients with Medicare cannot use these coupons. Lastly the medication is delivered to the patient. Because the drugs we use in rheumatology are specialty drugs, they must be delivered through a special pharmacy and most cannot be picked up from the local pharmacy.  

The common thread through the whole process is what is best for the patient. Determining what is best for the patient takes into account many complex factors. The above example is a very simplified version of the process of choosing the right recommendation to make for my patients. The main goal with any decision is to help the patient choose the right medication for him or her that will allow them to keep gardening, keep working, keep playing with their children. Arthritis is the number one cause of disability in this country. Having access to appropriate, effective treatment when the arthritis is active and manageable keeps people living active lives and helps prevent disability and joint replacements. It's the simple wisdom my grandmother passed down to me as a child - a stitch in time saves nine.