Snow Job

David Snow, the CEO of Medco, the pharmacy benefits management company, displays unbelievable arrogance and ignorance in a recent Wall Street Journal Health Blog entry:

Snow said the time has come for doctors to follow set protocols on how to treat patients, and to be paid based on whether they do it. Basically, ‘If X, then do Y,’ and ‘If Y, then do Z,’ sort of stuff. Snow concedes the public doesn’t trust the private sector to come up with these kinds of rules. So he wants some smart folks to get together in an “apolitical” body like the Fed, and do it themselves. “I’m fine with this big, national board creating this standard,” Snow says.

Doctors often bristle at the idea of these sorts of rulebooks, because they argue the rules don’t take into account the nuances and intangibles of caring for individual patients. Plus, they think insurers basically use such rules as excuses not to pay for things.

Perhaps that’s because that’s exactly what insurers frequently do.  He should know that.  After all, his company has been successfully sued for its prior authorization policy.

“I have no patience for a doctor who says, ‘I’m above it all, I don’t want to practice cookbook medicine,'” Snow says. Too many doctors, he says, just don’t keep up with the science. For instance, Medco last March asked 1,000 doctors who prescribe the potent blood-thinner Coumadin about a genetic test that the FDA has endorsed to keep patients from getting dangerous, excessive doses. Only three of them had heard of the test, he says. That’s an important test.

It is?  How important, exactly?  What is the cost of the test?  What are the false negative and false positive rates?  You see,  doctors ask those kinds of questions and don’t just start ordering a new test that was approved just a few months ago.  Or as Bussey, et al in Pharmacotherapy (link, registration required) put it:

Can genetic testing be used to determine the right warfarin dosage? Does such an approach reduce clinical complications and save the health care industry billions of dollars annually? The answer, quite simply, is maybe, but no one knows for sure. Although the concept may be attractive and this evolving area needs to be researched, good clinical data to support the use of genetic testing for warfarin dosing are not yet available. Also, it is important to realize that the impressive conclusions from the Brookings report mentioned above are based on supposition and projections, not on solid clinical outcome data. Furthermore, some experienced clinicians question whether genetic testing adds significantly to the information one may discern by carefully monitoring the inter-national normalized ratio (INR) and by taking into consideration the numerous patient-specific factors that influence warfarin dosing requirements, such as age, underlying disease states, and concomitant drugs.

Doctors do keep up with the science.  But keeping up with the science does not mean confusing the latest information with the best information or jumping on every bandwagon that rolls by until the science has been properly vetted.

Snow does offer a carrot to make this approach more attractive to docs. He says doctors shouldn’t be held accountable legally if they follow the protocol and their patients have bad outcomes. That’s what he calls tort reform.

 While Snow appears clueless when it comes clinical medicine, his views on the legal system may carry more weight given his first hand knowledge on the subject:

Medco Health Solutions, the largest pharmacy benefits management company in the United States, last week settled lawsuits brought by state and federal authorities by agreeing to stop switching patients over to more expensive drugs not prescribed by their doctors (these drugs were favored by Medco because of private “rebate” agreements with drug manufacturers). Medco also pledged to begin disclosing its rebate practices to employers, doctors and patients.

One Response to “Snow Job”

  1. very interesting blog post. pharmacy benefits management co.’s strike me as kind of a bad idea but since we don’t have them in Switzerland, i’m not too familiar with all the benefits and pitfalls. i don’t think any other european country has them either.

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