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Comment by vonmoltke | Hacker News Reader

> insurance software suggests cheaper generics to the pharmacist

I have never heard of pharmacists using "insurance software". The pharmacy system requests coverage from the patient's insurance, and it is either accepted or rejected.

Additionally, if there is a generic they just fill it, assuming the patient consents. In fact, pharmacists in many states are required to point out generic alternatives if they exist.

> requires the pharmacist to do the leg work of asking the doctor to change the Rx based on what the insurance company wants (ie the cheaper medication)

If a prescription requires modification, the patient is required to go back to their doctor. Pharmacists cannot just ask doctors for prescription modifications.

Where are you getting these ideas from?

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>If a prescription requires modification, the patient is required to go back to their doctor. Pharmacists cannot just ask doctors for prescription modifications.

>Where are you getting these ideas from?

This is not strictly true, at least in the US. I have had to wait while pharmacists contact the doctor to modify a prescription to sub something in due to availability issues.

The mail order service through my insurer will also do this to have doctors to order a 90 day supply rather than the usual shorter supply.

You're right, my statement was too absolute. What I meant to convey is that pharmacists cannot just ask for modifications without the knowledge and consent of the patient.

NexGen will suggest generics when you have a script for a name brand. It’s not coming from the insurance company.

Source: worked for RiteAid for half a decade.

Some states allow pharmacists to substitute generic drugs for name brand prescriptions. To my knowledge they don't need the doctor's permission, and can make the change on their own unless the doctor specifically requests the name brand medicine for some reason.

Yes, those are "Dispense as Written" (DAW) Laws.

http://beta.aan.com/globals/axon/assets/4698.pdf

In most states, just using the trademark name instead of the generic is not sufficient (which makes sense, since the generic names are usually quite wordy and hard to remember) the doctor needs to specifically write "DAW" if a generic cannot be used.

This begs the question, under what circumstance would it be reasonable for a doctor to insist on "Dispense as Written"?

Generics are not guaranteed to be identical, especially in the inactive ingredients. It is rare but not unheard of for someone to have a reaction only to one form of a drug.

Edit: I have a friend who has such an allergy, which was confirmed with double blind testing.

From the Center for Medicare and Medicaid Services. But like I said nearly no one knows any of this.

Go into any pharmacy and ask the pharmacist about “MTM” and gauge their reaction.

Look at outcomesMTM they are 1 of the 2 dominate insurance software vendors. Again you can ask nearly any pharmacist and they have an outcomesMTM portal that feeds them automated recommendations on behalf of the insurance carrier. Some of the bigger pharmacies, like Wal-Mart, have even removed the MTM portals from the individual stores already and created nationwide MTM centers. I even know of one company who uses pharmacy students (for free) to do this work for the insurers. Here is another tidbit for every recommendation the portal gives the pharmacist the pharmacy gets a “tip” (ie monetary bonus) to forward that to the doctor and if the doctor makes the change the pharmacy gets another tip. The only reason the insurers link up with the pharmacists to do their dirty work instead of the doctors directly is the insurers can’t pay the doctors the way they pay pharmacists to do their work bc of anti kickback laws.

>Pharmacists cannot just ask doctors for prescription modifications.

Again try asking any practicing family physician, ask them how many faxes they get a day from pharmacies requesting they change the patient Rx.

> From the Center for Medicare and Medicaid Services.

Please direct me to citations, not "try asking any X".

> Go into any pharmacy and ask the pharmacist about “MTM” and gauge their reaction.

MTM has nothing to do with insurance.

> Look at outcomesMTM they are 1 of the 2 dominate insurance software vendors.

outcomesMTM is not insurance software, it's pharmacy patient management software.

> Here is another tidbit for every recommendation the portal gives the pharmacist they pharmacy gets a “tip” (ie monetary bonus) to forward that to the doctor and if the doctor makes the change the pharmacy gets another tip.

That you need to substantiate with more than just "go talk to pharmacists", particularly in light of the above.

> Again try asking any practicing family physician, ask them how many faxes they get a day from pharmacies requesting they change the patient Rx.

I've had my pharmacy request changes on my behalf, if it was something simple (like getting the wrong dosage), and they have done so as a convenience, not because they were required to. I have never had them request a change without my consent or knowledge, and I would stop using such a pharmacy if it ever happened.

You have also completely ignored what I said about prescription changes not being necessary for generic substitution.

You are asking me to cite things but what are you citing? You are simply saying “that’s not true”.

>MTM has nothing to do with insurance.

It’s required by law To be provided by insurers/health plans. If you refuse to talk to pharmacists or doctors about it, fine, you can read the law 42 CFR 423.153. In short insurance companies, must provide MTM services to patient covered in their plans.

It is also the single biggest metric in determining an insurers star rating. How could it possibly be unrelated to insurance if insurance companies have to, by law, provide it and it effects their reimbursement/star ratings?

>outcomesMTM is not insurance software, it's pharmacy patient management software.

That’s funny...the software certainly does manage pharmacists...on behalf of the insurance companies.

Right from the outcomes homepage:

“Contracted with more than 50 U.S. health plans, OutcomesMTM provides MTM coverage to 5.5 million patients. The company links more than 100,000 local chain, independent and health-system pharmacy providers with contracted plans across the country.”

Why does outcomesmtm contract with 50 insurance companies? Why does outcomesMTM “link” pharmacies with contracted plans?

“Targeted MTM services are designed to help plan sponsors improve performance for key Star measures, including the triple-weighted adherence measures. Prompted by TIPs in the Connect™ Platform, pharmacists work with patients to impact adherence and optimize medication regimens.”

As to generic substitutions...there are laws from state to state that allow pharmacists to do it, UNLESS the doctor says the name brand must be dispensed. I’m afraid that’s common practice, so permission is required. Plus when it comes to Medicare patients a pharmacist isn’t going to just change the RX to generic because they know they: 1 get paid by the insurer through these MTM portals to make the recommendation and 2 get paid again through the portal if/when the doctor agrees to the change.

> You are asking me to cite things but what are you citing?

GP cannot prove a negative. If this software/system exists, the "burden of proof" is on you.

He said mtm has nothing to do with insurers and ask “where I got my ideas” I said CMS and cited the Law that Medicare insurers have to provide mtm to patients.

Then he said outcomesMTM is a pharmacy patient management software having nothing to with insurance, but it’s a software for insurers to pay pharmacies to provide mtm to the insurers patients and I quoted from their website. It’s really above and beyond ridiculous like me saying google is a search engine and someone say no it’s not give me a cite.

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