A Better Approach to Prescribing Medication

A Better Approach to Prescribing Medication 150 150 Jeb Phillips

A small change in the way a doctor prescribes a medication can make a big difference. Officials from the accountable care organization Partners For Kids use this example all the time: Abilify, a behavioral health drug, is usually priced per pill, not by strength of dose. Two 5 mg pills cost nearly twice the amount of a single 10 mg pill. Abilify is long-acting, so the single 10 mg pill is just as effective as the two smaller doses taken at different times.

Physicians don’t always know the drug’s half-life or pricing. An analysis by Partners For Kids found that if all its patients on Abilify took just one dose per day, the potential savings would be more than $300,000 per year.

That kind of overall savings is important for insurers, for Medicaid and for the entire health care system, says Chet Kaczor, PharmD, MBA, director of Pharmacy Services for Nationwide Children’s Hospital.

But if that’s too abstract, think about how the example affects a single child and a single doctor, he says. A patient is more likely to take every dose of a medication if there is only one dose per day. An adherent patient is a healthier patient. A healthier patient needs fewer trips to a provider, freeing the provider to see patients who may need care more urgently.

“The overall idea of efficiency in prescription practices is taking the best possible care of the patient,” says Cathy Kuhn, PharmD, a clinical pharmacist for Partners For Kids. “We are thinking about the patient’s time, the doctor’s time, ready access to medicine, cost and, ultimately, best outcomes.”

Partners For Kids is one of the oldest and largest accountable care organizations in the United States. With Nationwide Children’s as its hospital member, the organization works to keep children covered by Medicaid Managed Care Plans healthy in central and southeastern Ohio. Partners For Kids incentivizes its 1,000-plus member providers to focus on the quality and value of care instead of numbers of procedures or office visits.

Among its signature initiatives is its Pharmacy Program.

And one of the Pharmacy Program’s most important services is helping physicians understand best practices in prescribing medications. That includes giving guidance on insurance coverage, drug availability, drug costs and overall effectiveness of therapies for some very common conditions – asthma, allergies, ear infections, behavioral health issues, acne and others.

Some of the most recent guidance from the Partners For Kids Pharmacy Program is on the acid suppressive medication esomeprazole (Nexium). A prescription for a one-month supply of esomeprazole is $255. But if a provider writes a prescription instead for the over-the-counter Nexium 24HR – the same medication in every important way – the cost is $21 per month. Because of differing regulations on over-the-counter and prescription medications, a pharmacist can’t make the substitution for the less expensive option; the provider must write the prescription the correct way.

“It’s not always easy for a prescriber to figure out the right thing to do,” says Hosain Aghamoosa, PharmD, a clinical pharmacist for Partners For Kids. “If you think about how much time a provider might have with a patient, there may not be an extra few minutes to figure out which medications an individual insurer covers or which might be more expensive for a patient who is paying out of pocket. Physicians want to provide the best possible care for their patients. But if a patient can’t afford a medication or the insurance company doesn’t cover it, then a physician may actually be delaying therapy.”

Partners For Kids offers some information specifically tailored to its member providers. Prescribers don’t have to be members, though, to begin thinking about prescription practices, or to incorporate Partners For Kids’ attitudes into their work, its pharmacists say.

Partners For Kids makes some general medication guidelines publicly available on its website, PartnersForKids.org. Want to know if fluoxetine (Prozac) or sertraline (Zoloft) is the appropriate first-line medication for anxiety and depression? Or whether Ciprodex or Floxin Otic is the best initial step for the treatment of bacterial acute otitis externa?

You can find the answers in the “Resources” section of the website. (Spoiler alert: For anxiety and depression, the appropriate first medication is fluoxetine. For acute otitis externa, the answer is complicated, and a careful examination of the flow chart on the website will help.)

The guides are particularly useful for primary care doctors outside of metropolitan areas, Dr. Aghamoosa says. “In a big city, a child may see a psychiatrist for a behavioral health condition,” he says. “In a rural area, that same child has to rely on a primary care physician, who becomes a jack-of-all-trades. The guides help extend a pediatrician’s comfort level to match the needs of the patients in their areas.”

The website also includes a regularly updated document detailing many medication prices and coverages for Ohio’s five Medicaid Managed Care Plans. These won’t exactly match prices and coverages for every insurer or every state, but the document is a good guide for general trends, say Partners For Kids pharmacists.

Primary care physicians may also find medication management software and mobile applications, such as those produced by Micromedex Solutions and Epocrates, helpful, Dr. Kaczor says.

And the Partners For Kids Pharmacy Program has one more recommendation for prescribers: talk to your community pharmacists. Doctors are used to fielding calls from pharmacists who need a specific question answered about a prescription, or want to know if they can substitute one medication for another.

Doctors should remember the relationship works both ways, Dr. Kaczor says. Doctors can and should ask pharmacists about drug therapeutic information, costs, coverages and availability.

“Community pharmacists are the medication experts, and they’re just a phone call away,” Dr. Kaczor says.

About the author

Jeb is the Managing Editor, Executive Communications, in the Department of Marketing and Public Relations at Nationwide Children's Hospital. He contributes feature stories and research news to PediatricsOnline, the hospital’s electronic newsletter for physicians and other health care providers, and to Pediatrics Nationwide. He has served as a communications specialist at the Center for Injury Research and Policy at The Research Institute and came to Nationwide Children’s after 14-year career as daily newspaper reporter, most recently at The Columbus Dispatch.