WhiteCoat

Dr. Google, meet Pharmacist Bing

FDA decides whether to allow patients to purchase prescription medications over the counter for many common ailments.

This idea is controversial.

On one hand, deregulation would remove one of the largest barriers to receiving treatment for some conditions – the doctor’s visit. If no doctor’s visit is necessary to receive necessary blood pressure medications or diabetes medications, then patients don’t have to wait for an appointment and the patient/government doesn’t have to pay for the doctor’s visit. The move would also purportedly cost patients more money for their prescriptions because insurance companies (including Medicaid) don’t pay for over the counter medications. Therefore the costs for medications that go over the counter would be shifted to the patients who purchase the medications.

But on the other side, I’m sure that patients will “Bing” what medications they think they need, and the proposed plan would require patients to answer questions online or at a kiosk and then get input from a pharmacist before the prescriptions could be purchased. So there really isn’t unfettered access to the selected prescription medications.

According to the article, the American Pharmacists Association is embracing the concept while many doctors’ groups are opposing the idea. Pharmacists believe that their increasing role in a patient’s medical care will be a good thing while physicians see many of their “bread and butter” patients skipping appointments and instead going to the pharmacy kiosk.

Some of the conjectures about such a policy should be addressed.

Will prescription costs for patients go up? If patients have to pay out-of-pocket, then perhaps they would be paying more money for prescriptions, but I doubt that the amount of money would be much more than the copay they were previously paying. I imagine that most of the medications considered for over the counter use would be generic medications from the notorious “$4 list,” so the financial burden on a vast majority of patients would not be great.
However, there are certain medications that have no alternatives. Consider colchicine, vancomycin, and Plavix. Medications similar to these would continue to command a higher price. If patients need such medications or desire name brand medications, then they will keep going to the doctor in order to get their designer medications for a $20 copay.
However, medications that do have a generic or over the counter equivalent will see downward pressure on their pricing. Who in their right mind would buy a $300/month name brand medication when the $4 generics (or a combination of $4 generics) work just as well? So pharmaceutical manufacturers would have to justify the price of their expensive medications or would have to lower the price until patients felt that the price justified the benefits over generic medications. That’s free market at work.

Will the public be in imminent danger if they are allowed to self-prescribe? I doubt it. The Angry Pharmacist has a different take on the matter (read the post from behind a blast shield because it is rife with f-bombs). He believes that patients who take some medications need to be medically monitored for adverse effects from the medications. For example, patients who take ACE inhibitors may have deterioration in their kidney function from the medication and may even develop renal failure. If patients are worried about the effects on their kidneys, they can see their doctors for such testing. There are also some online labs that will provide direct-to-patient testing. But if we consider the renal function example, we can also look at Mexico where patients can purchase many medications over the counter. The rates of chronic kidney disease are no higher in Mexico where people can purchase ACE inhibitors over the counter than they are in the US where people cannot purchase ACE inhibitors over the counter. Maybe the adverse effects of medications are balanced by fewer people developing hypertension-related kidney disease because they are controlling their blood pressure. Lots of potential explanations, but we won’t know the real cause and effect without specifically studying the issues. Perhaps this isn’t the most accurate indicator of adverse effects from medications, but comparing health issues in the two countries may show that some of the health concerns raised against this policy are overblown.

Will pharmacists be happy with this policy? Decidedly not. If patients are allowed to purchase prescription medications over the counter, pharmacists all over the country are going to have another very significant and time-consuming task added to their laundry list of things to do while simultaneously being expected by their employers to fill prescriptions at the rate of no less than two per minute. Consider the intent of this policy. What the government is trying to do is shift patients from a paid physician service to an unpaid pharmacist service. Pharmacists are going to be doing a lot of extra work for which they will receive no extra compensation. And … if the patient does develop a serious side effect from over the counter medications provided at a pharmacist’s advice, then the patient (or the family of the dead patient) will have only the pharmacist or the pharmacy to blame because no physician was involved in prescribing the medication. Pharmacy malpractice insurance premiums are about to go up. The Angry Pharmacist notes that there is no one to sue in Mexico if there is a bad reaction to a drug. Do pharmacists really want the target painted on their backs?
This is a case in which I think pharmacists should be careful about what they ask for.

So what’s the right answer?

Deregulation. We shouldn’t stop with medications, either. We also need to deregulate radiologic testing, lab testing, and many medical devices as well.

Under this proposed policy, there shouldn’t be any input required from medical providers before patients purchase a medication, either. If patients want to ask about a medication before purchasing it, that’s fine. Patients don’t need pharmacist input to purchase vitamins, ibuprofen, Tylenol, Prilosec, or Claritin, so why should patients require pharmacist input before they purchase blood pressure medications? Just as with current over the counter medications, the onus should be on patients to research the side effects and interactions of medications before taking them. For that matter, why should patients need a doctor’s permission to get a CBC, have their cholesterol checked, or get an x-ray of an injured ankle? All that the regulations are doing is causing a barrier to access. Very few people are refused x-rays if they go to a doctor and really want them.

There should be some limits on what can be purchased over the counter, though. Controlled substances and antibiotics are a couple of examples of things that should still be off limits to the general public. In fact, so many physicians inappropriately prescribe antibiotics that I think antibiotics should be a controlled substance and that physicians should lose their ability to prescribe antibiotics if they demonstrate a disregard for proper prescribing practices. Coughs, runny noses, and simple toothaches do not require antibiotics, doc. We need to practice 21st century medicine.

So let patients purchase most medications over the counter. Yes, medical providers will still have to be Vicodin police and ZeePack police. For the rest of the medications, have at it. There will inevitably be some adverse outcomes and even deaths from wrong doses and from medication reactions. When these adverse outcomes occur, patients will gradually begin to see the value in the services that pharmacists and physicians provide.

We’re there to try to watch out for your interests, we’re not there to keep you from getting care and treatment that you truly need.

If you don’t believe me, you should be able to go and purchase medications yourself, knowing that you alone are responsible for any adverse outcomes that come from using the medications you purchase.

I think that is a fair trade-off.

UPDATE 05-14-2012:
Cross-posted at Kevin MD here with additional commenters.

 

16 Responses to “Dr. Google, meet Pharmacist Bing”

  1. girlvet says:

    Needless worry. This will never happen. AMA has too much power to let it happen.

    • WhiteCoat says:

      AMA doesn’t have as much power as it used to have.
      At the heart of the matter is decreasing health care spending and I think that the feds will do whatever they want if they believe that there will be a cost savings.
      Be interesting to see what happens.

  2. DataGirl says:

    To trade up from RX to OTC the medication must have a long history and somewhat sound safety profile. And the NDA/ANDA holder will have to initiate this process – probably won’t happen until their patents expire so that they can capitalize as much as possible.

    And costs will still be high. Think Zyrtec…cost the patient less when RX (around $10) than it does OTC (easily $30). All it does is just move the cost of treatment around from one place to another and probably won’t affect total healthcare costs in the end anyway.

    • WhiteCoat says:

      It will shift the costs from the government to the patient, which is what the government wants.
      Government doesn’t pay for Zyrtec any more, patients do. Then free market comes into play. Does Zyrtec’s higher price justify its benefits over Claritin or Benadryl? If not, few people purchase it. Then they either lower the price or let the medications expire on the shelves.

  3. davidhowardojai says:

    Interesting proposal. The new pharmacistcentric model sounds very good to me. I have lived in both Spain and Mexico. In Spain the consumer/pt can pretty much buy anything w/o rx.. The instant consult is with a highly trained pharmacist, typically the business owner and both experienced and accountable to the community. In Mexico, the same system holds except the “pharmacists” may be mere clerks and accountable to no one. Mexico also has a patient culture that thinks antibiotic just means stronger medicine, so customers typically demand them for anything, including common cold. If injectable, all the better. So obviously, you have to control that. Kiosk questionnaire, however, should work fine for a panoply of meds that require rx in USA. That’s in an ideal world, however, with no vested interests rigging the system and maintaining the status quo.

    • ThorMD says:

      I have to agree with you. I’ve traveled a lot in Europe and Australia/NZ and their model makes so much more sense. Their pharmacists can prescribe and treat so many conditions. They can say “no” to antibiotics for a URI just as easily as a doctor can, and then offer Robitussin AC or Tessalon Perles. In Spain, they can prescribe Ambien for insomnia. When the Euro was much weaker against the dollar, I know several people who would stock up on Ambien when they went to Spain as it was a lot cheaper than in the US. In that culture, people don’t even go to the doctor for a viral illness because there’s nothing a doctor can add.

  4. Matt says:

    “If you don’t believe me, you should be able to go and purchase medications yourself, knowing that you alone are responsible for any adverse outcomes that come from using the medications you purchase.”

    hahahaha. if only the govt would actually allow people to be responsible for their own decisions.

    I feel like this is a ploy of the lawyers, looking for a new income stream.

    • doc99 says:

      This may sow the seeds for a new wave of class action suits against CVS, RiteAid, Target and WalMart.

    • WhiteCoat says:

      You may be right.
      Walgreens and Walmart have a lot deeper pockets than most hospital systems and physicians.

      • DensityDuck says:

        True, but Walgreens and Walmart can purchase med-mal coverage at group discount rates, rather than writing ten zillion individual policies and raking in the cash.

  5. Anonymous says:

    It makes sense to me that prescription drug advice would come from the people who spend the most time studying prescription drugs.

    “hahahaha. if only the govt would actually allow people to be responsible for their own decisions. ”

    As long as there are democrats this won’t ever happen.

  6. Antigonos says:

    Very good post. As both a health care provider [CNM] and a health care consumer [type 2 diabetes, among other conditions], the amount of running around I do to get the necessary prescriptions and referrals actually limits the time I have to care for myself.

  7. Don says:

    IRS Rules need to change though. I use a health savings account to pay for my meds. I used to be able to use it to pay for OTC. But IRS changed the rules and now I have to have a prescription to use my HSA dollars.

  8. Lior says:

    I’m all for allowing patients to self-medicate and bear the risks. One significant advantage would be improved doctor–patient interaction. When i teach there is a vast difference in attitude between students who are taking the course because “they have to” (it’s required by their major) and students who take the course voluntarily. It’s much more enjoyable to interact with someone who individually decided they want you talk to you.

  9. jb says:

    To me it is fundamentally an issue of personal freedom. Do I have a right to my body? Do I have a right to put in to it what I want? I believe the answer if yes. We should not be forcing our services upon people through coercive legislation that only allows them the ability to get meds only with a prescription. People will still use our services to guide them through the process. I personally prefer a voluntary relationship with patients. But does it really take a doctor to get a statin drug and periodic LFT’s? I could do that myself. I feel the same way about coercive legislation like EMTALA.
    As far as antibiotics are concerned, I feel if the government wants us to prescribe more rationally, then they need to give us protection from lawsuits in the event our failure to provide an antibiotic harmed someone. They should also eliminate patient satisfaction scores as part of the consideration for reimbursement. That will go a long way. Really , the solution is to get the government out of healthcare altogether.

  10. DensityDuck says:

    If I don’t change the oil in my car, or make sure the tires and brakes are not too worn, then my car can suffer severe damage. It might be rendered inoperable, and in extreme situations my failure to maintain my car might pose a threat to life and limb.

    And yet there is typically no government requirement that my car’s maintenance status be verified, or that my car maintenance be performed by a professional (or, indeed, that it be performed at all.) And where those things are required, it’s a state-level requirement rather than a Federal-level one.

    Meaning that hundreds of millions of Americans are already taking personal responsibility for life-or-death decisions about themselves. Why should medication be different?

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