Health care currently constitutes over 16 percent of our national gross domestic product. As Americans, it behooves all of us to ensure that every health care dollar is spent prudently. The importance of doing so is particularly amplified in the area of pre scri ption medicine. This concern impacts both the way physicians prescribe medicines and the way pharmacists fill those pre scri ptions. When cost is the primary issue, the pharmacist may switch the customer from a brand name drug to a generic.
Many drugs offer generic equivalents. This gives the patient an opportunity to save money while receiving the same desired effects. For drugs that do not have equivalent generic versions, no substitutions should be made for that original unless a doctor approves. Two drugs can treat the same illness, but those drugs can feature different dyes and other components that may mean the difference between a debilitating side effect and a comfortable, effect-free outcome.
There is now legislation being written to compel insurers to cover any FDA-approved drug, authored by Senators Jeffrey Klein, Thomas Duane and John Sabini. This legislation will provide patients much-needed access to some very important drugs, while allowing the physician the freedom necessary to make the right pre scri ption. This will hopefully reduce the pressure exerted on me to prescribe cheaper drugs from insurers, while cutting down on the time my staff spends researching formulary lists, and appealing to insurance companies over the phone each day.
In addition, this legislation will:
• Force insurers to cover a more expensive drug prescribed by a doctor, if all other, cheaper drugs recommended by the insurer are tried first.
• Prevent insurers from removing critical drugs from their formularies, in most instances, to interrupt a patient’s current treatment regimen. This ensures that a patient can receive coverage for a drug even after it is removed from a formulary list under the same terms that existed before the change.
• Require the insurer to submit their reasons for denying coverage of a drug to the New York State Department of Insurance Guidelines.
This legislation is important, because it frees me to do what is right for the patient, without constant justification of the cost. It will also benefit African-Americans and Hispanics, who are disproportionately impacted by illnesses like heart disease and diabetes. Some of the most effective drug treatments for these conditions are out of reach for these communities because of cost.
Recently, insurance companies have begun “pay-for-performance” programs, where they will offer physicians financial rewards if they meet a certain threshold of generic pre scri ptions every month. This puts me, the physician, in a difficult spot. Clearly, I have examined my patient and know what drugs should be prescribed, but I am being pressured by an insurer to prescribe something cheaper.
Personally, if I am asked to authorize a change in medication for a patient, I would need to have access to that patient’s medical history and examine the patient myself before determining the best pre scri ption to treat the condition. I have been asked to authorize changes in medications for patients of colleagues in the past, and have refused. Had I prescribed a new medicine, like the pharmacy had asked, or authorized the switch, without properly examining that patient, such action could have negatively impacted the patient, and I would never have known about it! How then, can an insurer—who has never examined a patient as I have—make a critical decision about pre scri ption medications for that person without knowing their past medical history?    

Harold Sokol is president of the Third District Branch of the Medical Society of the State of New York and former president of the Medical Society of the County of Albany.