Tom Philpott
has been breaking news for and about military
people since 1977. After service in the Coast
Guard, and 17 years as a reporter and senior
editor with Army Times Publishing Company,
Tom launched "Military Update,"
his syndicated weekly news column, in 1994.
"Military Update" features timely
news and analysis on issues affecting active
duty members, reservists, retirees and their
families. Tom also edits a reader reaction
column, "Military Forum." The online
"home" for both features is Military.com.
Tom’s freelance articles have appeared in
numerous magazines including The New Yorker,
Reader's Digest and Washingtonian.
His critically-acclaimed book, Glory Denied,
on the extraordinary ordeal and heroism of
Col. Floyd "Jim" Thompson, the longest-held
prisoner of war in American history, is available
in hardcover and paperback.
Congress five years ago approved a Defense Department plan to slow
pharmacy cost growth by creating a uniform drug formulary for the
military, and by imposing higher co-payments on drugs knocked off
the list as too expensive and no more effective than other medicines.
Finally, the process of identifying these "non-formulary'' drugs
has begun.
The first two are likely to be Teveten, a heart medication with only
2200 known military users, and Nexium, a heavily-marketed drug to
treat acid reflux and peptic ulcers, and used by more than 137,000
beneficiaries.
Over time, the formulary review process should encourage hundreds
of thousands of beneficiaries to switch to more cost-efficient medicines.
But officials said they intentionally made their first recommendations
modest, to avoid impacting too many beneficiaries before they understand
the process.
A drug shifted to non-formulary status can't be dispensed on base
unless prescribed by a staff physician and the patient can show medical
necessity. Non-formulary drugs remain available through the TRICARE
Mail Order Program and the TRICARE retail network, but for a higher
co-payment.
For mail order, the charge is $3 for a 90-day supply of a generic
drug, $9 for a formulary drug and $22 for non-formulary. The same
tiers exist for the retail network but the co-pays cover only 30 days
of medication.
The Defense Department's Pharmacy and Therapeutics Committee began
screening the uniform formulary starting with drugs in two classes,
and comparing clinical effectiveness and cost. The first class, Angiotensin
Receptor Blockers (ARBs), is for hypertension and other heart conditions.
Seven ARBs currently are on the uniform formulary.
The P&T Committee, which includes senior physicians and pharmacists,
studied clinical trial data and found that Teveten had no significant
advantages over the other drugs and was less cost-effective.
The second class reviewed is Proton Pump Inhibitors (PPIs) for treatment
of acid reflux disease and peptic ulcers. Five PPIs are on the current
formulary. One is an over-the-counter drug called Prilosec, Zegerid
or by generic names. Four PPIs -- Prevacid, Aciphex, Protonix and
Nexium -- require a prescription. All five, the committee found, have
the same clinical effectiveness but Nexium is the most expensive.
Dr. William Winkenwerder, assistant secretary of defense for health
affairs, will make the final decision on formulary changes. To help
him, the law that authorized the uniform formulary also created a
Beneficiary Advisory Panel to review P&T recommendations and to comment.
At its first public meeting in Washington D.C. March 23, the beneficiary
panel endorsed shifting the two drugs to non-formulary status. But
a majority disagreed with the committee's call to move Teveten off
the formulary 30 days after a final decision, and Nexium after 90
days.
Panelist Sydney Hickey of the National
Military Family Association said she won't support a transition
of less than 180 days for any drug getting bumped, until Defense officials
show they have a plan to notify impacted beneficiaries about the change.
Other association representatives on the panel, all of them strong
beneficiary advocates, agreed. A majority advised Winkenwerder to
reject of the 30-day and 90-day implementation plans.
Dissenting from the majority were three doctors, all of whom expressed
frustration that the P&T committee had moved too timidly in its first
try to shape a more cost-efficient formulary.
"If two ARBs out of seven were found to be clinically useful and
cost effective, why are six [retaining] formulary status?'' asked
Dr. Jan Prasad, a TRICARE network cardiologist from Phoenix. "That's
ridiculous.''
Navy Cmdr. Denise Graham, a pharmacist supporting the P&T review process,
said the idea was, "Let's see how this plan works, impacting the
least amount of beneficiaries that we can, and still get a cost-benefit.''
Another panel member, Dr. Jeffrey L. Lenow, a professor at Jefferson
Medical College in Philadelphia, said he also had expected more aggressive
cost-savings decisions from the P&T committee.
The military spent $77 million on ARB drugs last year. Teveten represented
only one percent of those costs.
"I'm saying, `You're chasing after one lousy ARB, which you have
a tiny percentage of patients on, and you'll go back and claim victory…Look
at all the energy and time that went into this ARB review. Albeit
excellently done, its net yield is going to be negligible,'' said
Lenow.
The panelists were advised that military pharmacy costs are nearing
$5 billion a year. About 6.4 million beneficiaries had 100 million
prescriptions filled in 2004. The least efficient pharmacy option
for the military is the TRICARE retail network, which handled 31 percent
of the prescription workload last year yet accounted for 52 percent
of drug costs.
Another beneficiary advisory panelist, Dr. Martha Miller, medical
director of Health Net Federal Services, said keeping on the formulary
many more drugs than needed for effective patient care "doesn't make
a lot of sense for those of us more familiar with the commercial world.''
But Chuck Partridge, representing the National Military and Veterans
Alliance on the panel, said some patients have difficulty with one
drug but not another, even though clinical trials show them to be
equally effective.
"From a beneficiary's point of view, I would like to see as much
choice as possible,'' Partridge said.
In June, the beneficiary panel will hold its second meeting to review
P&T formulary recommendations for four more classes of drugs.
To comment, write Military Update, P.O. Box 231111, Centreville,
VA, 20120-1111, e-mail milupdate@aol.com or visit www.militaryupdate.com
