There is a simple truth about drug formularies. Yes, they are crafted using a variety of strategies that boil down to cost containment—for the insurance company and the plan sponsor. The ultimate goal of a formulary, however, is to provide patient access to the affordable, safe, and medically appropriate treatment. Since diseased states, such as diabetes, can have multiple therapeutic options (generic and brand), formulary designers juggle many variables to achieve the delicate equilibrium between clinically appropriate and cost-effective therapies. Could, then, the way physicians get their drug and formulary information affect thinking about the big picture?

I reached out to Dr. Kelly Wirfel, M.D., Clinical Assistant Professor of Medicine (Diabetes, Endocrinology, and Metabolism) and Medical Director at UTP-Bellaire. She is the Co-Director of the UTP Bellaire clinic and her patient base largely includes individuals coping with diabetes. We discussed how the quest for timely drug and formulary information impacted her practice.

Physicians, including specialists like Dr. Wirfel, struggle to get accurate and less confusing formulary information needed to provide the best care. “In the recent past, I found it progressively more difficult to get information when I needed it”, says Dr. Wirfel. For example, diabetes innovators are frequently placed on non-preferred tiers and there are often further complexities within the key classes. When this happened, she says, “Despite our best efforts, we were often not able to tell patients during the visit what prescriptions their insurance would cover.”

“Despite our best efforts, we were often not able to tell patients during the visit what prescriptions their insurance would cover.”

Exclusionary formularies have become ubiquitous within the Pharmacy Benefit Managers (PBMs) world as a way to pro-actively manage costs. When a PBM removes one manufacturer’s drug from their formulary or tier, the remaining competitor is incentivized— by a likely significant increase in market share and/or an exclusive position on the PBM’s formulary — to provide lower cost therapies. Patients may be disadvantaged, however, if they require therapy that becomes excluded or is moved to a higher co-payment or coinsurance category.

Some patients with chronic diseases like diabetes need access to combination therapies when individual therapies have not been able to successfully manage their disease. Also, access and drug adherence with diabetes medicines are crucial not just for controlling diabetes, but also for preventing the manifestation or complication of other health problems. Consequently, access to timely formulary information can improve or threaten the best outcomes, especially for vulnerable populations–the elderly, low-income, and/or the chronically ill.

Patients unable to pay the full cost of a non-formulary drug may not fill their prescriptions. Even patients who can afford off-list medications usually prefer cheaper, yet still clinically effective alternatives. There are also other patient costs— time and monetary— that arise from expedient access to formulary information, such as additional office visits and laboratory monitoring. The system of drug tiers and pre-approvals can turn formularies into a daunting obstacle course for both the patient and the physician.

For physicians, effective use of drug formularies is integral to the big picture of patient care. So, physicians spend a considerable amount of uncompensated time and resources navigating at the helm of this process. Working effectively with formularies can involve researching drug classifications, getting pre-approvals, engaging in multiple back-and-forth dialogues with pharmacists, and even allocating clinical staff to wrangle pre-authorization requests. Wirfel readily admits, “I am happy to comply because I know that I am at the whim of the insurance companies” to ensure patient drug adherence via affordable options.

Accordingly, it is essential that health care providers obtain exclusion announcements, a list of covered alternatives, and details on the exception process.

“I just want to give my patients the best care,” says Wirfel. “But, unnecessary complications, such as those changes and restrictions within classes were, for the most part, my biggest objection.”

Any delays in receiving formulary information affect the workflow of the provider, their office, and collaborative healthcare practitioners. “I spent more time in the office working to get current, accurate information.”, says Dr. Wirfel.  “I saw that colleagues, RN, and other clinical personnel were doing this too. All of this slows things down and impacts our ability to deliver the best care.” Physicians are not directly compensated or reimbursed for researching formulary lists or engaging in back-and-forth calls with pharmacists.

Collaborative decision-making, a key component of patient care, can also be jeopardized. Dr. Wirfel found that “electronic records systems were routinely not accurate”, adding to the complexity.

The solution seemed simple: put together information on an integrated platform that ensures the accuracy and timeliness data. Seeing all therapies, including the covered options, for a specific disease state and the co-payment options would make it easier to choose “the one that works best for the patient’s health and resources.” This could “increase patient engagement” and improve outcomes overall.

Xpress integrates patient electronic records with drug therapy and insurance information. This enables doctors like Wirfel to make a more informed and effective drug therapy decision.

Wirfel attests, “There weren’t many effective options to deal with reality this until Xpress. Now, Xpress offers a system that keeps us up-to-date”.

How does this sharpen the big picture? “Medicine has changed so that we now spend more time with computers and technology and less with the patient”, says Wirfel. The technology we use, therefore, must not just facilitate but improve patient care. Achieving gains in doctor workflow efficiency, patient engagement and drug adherence can be the beginning.