Doctors pressured to write prescriptions for OTC drugs

Washington Requests for prescriptions to purchase over-the-counter medicines using flexible spending accounts or health savings accounts have become an unnecessary burden for doctors and patients, according to congressional testimony from physician organizations, patient advocates and representatives of OTC drug companies.

Lawmakers are considering the repeal of a health system reform law provision that requires prescriptions for medicines and drugs, even those that have been approved by the Food and Drug Administration to be sold without a physician's order, before patients can cover the costs with funds from tax-preferred health accounts, including health reimbursement arrangements. The provision took effect in 2011, and physicians report that they now are being saddled with the task of writing otherwise unnecessary prescriptions for medications to fight the common cold, flu or allergies.

A coalition that includes the American Medical Association, AARP, the Consumer Healthcare Products Assn., the National Assn. of Manufacturers and the U.S. Chamber of Commerce supports repealing the reform law provision. Limiting tax-preferred coverage of medications that can be purchased over the counter has increased costs and impeded patient care, the groups say.

“The AMA supports two pieces of legislation, HR 2529 and S 1368, which would eliminate this provision and allow patients to save time and money when purchasing over-the-counter medications to treat minor ailments and injuries,” AMA President-elect Jeremy A. Lazarus, MD, said in a statement.

During an April 25 hearing, the House Ways and Means oversight subcommittee discussed the proposed repeal legislation and the impact that the reform law has had on physicians. Republicans and some Democrats support rescinding the provision to free up dollars from tax-preferred accounts.

Rep. Charles Boustany Jr., MD (R, La.)

The current provision “leads to increased wait times in doctors' offices, greater costs both in time and dollars for consumers, and delays in obtaining treatment,” said Rep. Charles Boustany Jr., MD (R, La.), the subcommittee's chair. “This policy was not enacted to cure a problem or promote better health care spending — this was done to raise revenue, pure and simple.”

Responding to requests to write orders for OTC drugs has become an administrative problem for physician practices, said Joel M. Feder, DO, a partner at Overland Park (Kan.) Family Health Partners. He represented the American Osteopathic Assn. at the hearing.

Insulin and medical supplies that are not considered drugs or medicines, such as bandages, contact lens solution and blood sugar testing kits, do not require a prescription for the use of FSA, HSA or HRA money under the reform law. Thus, practice staff often must make a preliminary determination as to whether a physician's order is needed. The law also has created conflict between doctors and patients, physicians report.

“In my experience, most patients feel inconvenienced and are unhappy with this situation and enter my office with that mindset,” Dr. Feder said. “As a result, I am potentially placed in a difficult and uncomfortable situation with a patient by possibly refusing to provide a prescription, charging for that service, and/or recommending that patient purchase a different, higher-cost alternative.”

For instance, Dr. Feder said he will not write prescriptions for medications that a patient seeks as a source of energy. The patient-doctor relationship would be fractured if that person left the practice as a result and sought an order from another doctor.

“I, along with my colleagues, strive to empower my patients to make decisions regarding their health while still coordinating their care and visiting them when necessary,” he said. “As I work to coordinate the care for my patients … I aim to put practices into place that allow them to stay out of the office as a result of good health.”

The use of OTC medicine is estimated to save the system $102 billion a year, in part through a decreased need for office visits and diagnostic tests, according to a 2012 study commissioned by the Consumer Healthcare Products Assn. This includes about $25 billion in savings from utilization of lower-cost medicines instead of drugs that are kept behind the pharmacy counter.

The reform law, which will limit the amount that patients can set aside in FSAs to $2,500 a year beginning in 2013, is expected to increase government revenue by $18 billion over nine years — revenue that will be used to help expand health coverage to the uninsured population, said Paul Van de Water, PhD. He's an economist and senior fellow with the liberal Center on Budget and Policy Priorities in Washington. Republicans on the subcommittee referred to this as a cost shift from one population segment to another.

Only one in seven working Americans has a flexible spending account or health savings account, and most workers do not have the option of opening such an account through their employers, Van de Water said.

The cost of repealing the over-the-counter provision would be $7 billion over 10 years, said Rep. Xavier Becerra (D, Calif.). He questioned why Congress should offset what effectively is a tax break for just a segment of the population.

“We're giving a select group of Americans a chance to deduct the cost of that flu medicine from their taxes, while the majority of Americans buy the same medicine, buy the same pills, but don't get to deduct those costs from their taxes,” he said. He noted that the reform law does not prevent patients with accounts from accessing the medicines, and the accounts still can be used to cover co-pays, medical care and medical supplies.