Most people understand that the poorly designed US healthcare system (low quality, too costly) is taking a toll on the public’s health and pocketbook. What most people do not understand is that the system is also taking a toll on the healthcare providers in the form of “physician burn-out.” Physician burn-out is a condition in which physicians lose satisfaction and a sense of efficacy in their work and this has an adverse effects on the health of the physician’s patients.
There are many factors that contribute to physician burn-out including poorly designed electronic health records, a Byzantine billing system, and innumerable Federal, State, and insurance company “rules” that interfere with a physician’s ability to provide care to their patients.
One underreported factor which contributes to physician burnout is the commercial health insurance company’s medication formularies, which force physicians to use a “formulary compliant” medication even when they do not believe it is in the best interest of their patient.
At least several times a day, I receive notifications from a pharmacy or insurance company that a medication a patient has been taking for years or a newly prescribed medicine is not on the patient’s medication formulary. Usually, the document does not inform me which similar medications are on the patient’s medication formulary. When this happens, it becomes a reoccurring guessing game. As the pharmacy will not tell me during a phone call which medicine is on the formulary, I send another Rx to the pharmacy and wait to see what happens. This delays the patient’s treatment and is frustrating to the patient, pharmacist, and physician. Worst still, the patient may need to return for another office visit to learn about/how to administer this new medicine.
Sometimes I am told that I need to use a specific alternative formulary compliant medication which is in the same “class” as the prescribed medicine. For example, there is a class of diabetic medicines referred to as “SLGT2i.” The first SLGT2i, Jardiance, came to the market in 2014. Since then various companies have brought to the market other SLGT2i including Invokana, Farxiga, Steglatro.
While there are studies showing that each SGLT2i meets the minimal FDA requirements, some SGLT2i are supported by higher quality data than the other SGLT2i medications.
In addition, while all the SGLT2i share some of the same side effects, some specific SGLT2i appear to have additional adverse side effects, such as Invokana, which was associated with an increased risk of amputation in some studies.
Another class of diabetic medications is GLP1RA; there are 8 GLP1RA including Byetta, Bydureon, Victoza, Lyxumia, Tanzeum, Adlyxin, Trulicity, Ozempic. Here too, while the broader benefits arising from the use of the GLP1RAs are true for all GLP1RAs, the magnitude of their benefit and the side effect profile varies by the individual agents. From a recent academic publication on this subject: “Since the efficacy and tolerability, dosing frequency, administration requirements, and cost may vary between agents within the class, each agent may offer unique advantages and disadvantages … differences exist in terms of magnitude of effect on A1C (reducing glucose concentration) and (reducing) weight as well as frequency and severity of adverse effects.”
Currently, there are nine “classes” of medication which can be used to treat diabetes as well as several different types of insulin (shots.) And, within each medication “class” there are many medications, each has a unique benefit, risk, and side effects profile.
While your physician is likely smart, they are probably not a genius. It is literally impossible to know all the dosing schedules, benefits and side effects of every medicine in every class of diabetic medications.
In this patient, I wanted to use Jardiance but the patient’s insurance company told me that I must use Steglatro, which, in my opinion, has much less supporting scientific data than Jardiance, and is a medication I have never used.
In the past, physicians were taught to learn 2–3 medicines in each “class” and limit their prescribing habits to the medicines they know well. This ensured that the physician could optimize the risk/benefit ratio for each patient.
As a result of the restricted medication formularies, our healthcare system now forces the physician to choose between three undesirable options.
The physician may:
- prescribe a medicine they do not comprehensively understand
- prescribe a medicine the patient can not afford (e.g Jardiance cash price is about $600/month)
- ask the insurance company to allow the patient to take the prescribed medicine at a reduced price, which rarely works and takes the clinical staff away from direct patient care.
So far, we have only talked about one disease, diabetes. Imagine the level of frustration the physician experiences when they are dealing with many, many diseases and each has several different classes of medications with many medicines within each class.
In the end, the physician is really given no option but to prescribe a medication whose risk/benefit ratio they may not be able to fully assess or have never used.
Clearly, this is not in the best interests of our patients.
Hayward Zwerling, M.D.