The Why and How of High-Value Prescribing
Am Fam Physician. 2016 Feb 15;93(4):262-263.
Much of the care provided in the U.S. health system is low value. Administrative waste and inappropriate use of health care services account for $750 billion annually, or about 30% of total U.S. health care spending.1 Although the U.S. system is by far the most costly in the world, its health outcomes are worse than those of many other countries. To improve the value of the health care they provide, physicians are professionally and ethically obligated to prevent harm, eliminate waste, and serve as stewards of health resources.2,3 Prescription drugs account for 10% of U.S. health care costs, or about $260 billion per year.4 Therefore, high-value prescribing is one area that family physicians should focus on, using the following five strategies:
1. Be a healthy skeptic, and be cautious when prescribing new drugs. Physicians often reach for prescription pads when there are nonpharmacologic options that should be considered first. Although it seems that new, expensive medications arrive on the market constantly, very few are novel and useful in primary care.5 Remember: “newly approved does not always mean new and improved.”6 Physicians should apply healthy skepticism to new medications, and should avoid prescribing new, non-breakthrough medications until their safety and effectiveness have been established and until they are shown to be safer or more effective than more established alternatives. This process often takes years.7
2. Apply STEPS and know drug prices. Physicians should apply STEPS, popularized in this journal, to decision-making about new medications. STEPS analyzes the safety, tolerability, effectiveness, price, and simplicity of a drug.8 Effectiveness should be measured by patient-oriented outcomes, not surrogate markers or disease-oriented measures. Understanding drug prices is essential to the use of STEPS; these are available from a number of online resources, such as the website http://www.goodrx.com.
3. Use generic medications and compare value. Most drug classes have generic medications available at a fraction of the price of newer, brand-name medications. Generics are as effective as brand-name medications,9 have often been on the market longer, and have proven records of relative safety. For example, there are five generic statin drugs available in the United States for prevention of cardiovascular disease. If patients were prescribed generic instead of brand-name statins, $5 billion would be saved annually.10 There are five generic selective serotonin reuptake inhibitors, one generic noradrenergic antagonist, and one generic serotontin-norepinephrine reuptake inhibitor approved in the United States for treatment of major depression. Consumer Reports Best Buy Drugs (http://www.consumerreports.org/cro/health/prescription-drugs/best-buy-drugs/index.htm) is a useful resource that makes consumer-focused, cost-effective medication recommendations.
4. Restrict access to pharmaceutical representatives and office samples. Pharmaceutical representatives influence physician behavior and can lead to irrational prescribing.11–13 Sales representatives often focus on new medications that have unproven long-term benefits and uncertain safety. A sample closet may also be detrimental to high-value prescribing. Use of samples leads to higher medication costs—both out of pocket and total—and irrational prescribing.14,15 Although industry interactions with U.S. practice and residency programs have decreased, one-half of family medicine residency programs allow some industry interaction.16,17 Many national leaders have called for an end to pharmaceutical industry access to office practices and training programs.18,19
5. Prescribe conservatively. A systematic approach advocated by the World Health Organization can help minimize poor-quality and erroneous prescribing. It states that physicians should evaluate and clearly define the patient's problem, specify the therapeutic objective, consider nonpharmacologic therapies, evaluate therapy regularly, and consider drug costs when prescribing.20 Another approach advises physicians to think beyond drugs; to practice more strategic prescribing, including learning to use a few drugs well and avoiding switching medications often; to maintain heightened vigilance about adverse effects of medications; to use caution and skepticism regarding new drugs; and to work with patients toward a shared agenda.21
Adopting these suggestions for high-value prescribing can help family physicians increase the quality of care, decrease costs, and fulfill our professional obligation to provide health care that is based on the wise and cost-effective management of limited clinical resources.2
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4. Kaiser Family Foundation. Health care costs: a primer. http://kff.org/report-section/health-care-costs-a-primer-2012-report. Accessed June 7, 2015.
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17. Brown SR, Evans DV, Fugh-Berman A. Pharmaceutical industry interactions in family medicine residencies decreased between 2008 and 2013: a CERA study. Fam Med. 2015;47(4):279–282.
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19. Institute of Medicine. Conflict of interest in medical research, education, and practice. http://www.iom.edu/Reports/2009/Conflict-of-Interest-in-Medical-Research-Education-and-Practice.aspx. Accessed October 7, 2015.
20. Pollock M, Bazaldua OV, Dobbie AE. Appropriate prescribing of medications: an eight-step approach. Am Fam Physician. 2007;75(2):231–236.
21. Schiff GD, Galanter WL, Duhig J, Lodolce AE, Koronkowski MJ, Lambert BL. Principles of conservative prescribing. Arch Intern Med. 2011;171(16):1433–1440.
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