Dispensing drugs on site may help with patient compliance

Morris Kliger, D.O., a physician in Lansdale, Pa., has patients tell him that they are overwhelmed by the price of prescription drugs. One 72-year-old man had spent $2,200 in less than five months on nine medications, quickly reaching Medicare's donut hole.

The man had considered not filling some of his prescriptions so that he could pay his bills.

Helping patients get affordable drugs so that they can comply with their treatment plans is the main reason that Dr. Kliger started dispensing prescription drugs from his office. He recently sold a 100-day supply of lisinopril, for example, for $17 to the 72-year-old patient, much less than the hundreds of dollars he'd paid out-of-pocket for some of his pills.

“A lot of people, especially the Medicare population, are not taking their drugs because they can't afford them,” said Dr. Kliger, who is among a small percentage of physicians who sell medications from their offices. “This is a way we could help fill the gap a bit and supply certain medications for what we thought was an affordable price.”

Ethical concerns

Dr. Kliger uses a system from QuiqMeds, a Blue Bell, PA-based company that stocks a secure machine with 35 medications that he commonly prescribes. While he cites affordability, better compliance and convenience as reasons to sell prescription drugs, doctors can also, depending on what system they use, modestly boost their income by doing it. A doctor using the QuiqMeds system, for example, dispenses drugs and can then set fees to cover costs, said Mel Stein, the company's CEO.

Some experts worry that a profit motive could lead doctors to overprescribe and that the practice could impact patient safety. With in-office dispensing, the pharmacist can no longer potentially catch a prescribing mistake or counsel patients on proper use of a drug.

“There is an ethical concern in a way because obviously there is a profit motive,” said Michael Cohen, president of the Institute for Safe Medication Practices in Huntingdon Valley, Pa. The system may lead doctors to prescribe more drugs, he added, “and we know that as the number of drugs a patient takes goes up, the potential for harmful interactions and side effects goes up.”

ACP has no policy specifically focused on doctors dispensing drugs, although it does have a statement that discourages doctors from selling products from their offices. A 1999 position paper states, “Physicians have a particular duty not to exploit the patient's trust in them in order to enhance income. When deciding whether or what products to sell out of the office, physicians should carefully consider such criteria as the urgency of the patient's needs, clinical relevance to the patient's condition, adequacy of evidence to support use of the product, and the patient's geographic and time constraints in obtaining the product.”

Gail J. Povar, FACP, a Bethesda, Md. internist who was the lead author of the policy statement for ACP's ethics committee, said that she could think of only a few scenarios where a patient might truly benefit from getting a drug on the spot, such as a patient who comes in with herpes zoster.

“Receiving the first dose of the appropriate antiviral while in the doctor's office could reduce the chance of post herpetic neuralgia,” Dr. Povar explained. Likewise, a patient seen in the evening for severe streptococcal tonsillitis could also benefit from getting the first doses of antibiotics directly from the doctor if no nearby pharmacy is open at night.

“Physicians who assume the role of pharmacist should be prepared to assume that role in its entirety,” she said, including checking for potential interactions with other medications, providing printed educational material, checking patient insurance coverage, maintaining medication records and monitoring recalls.

Boosting patient compliance

There are no firm numbers on how many doctors sell prescription drugs. A June 2006 article in the journal Physicians Practice estimated that only 7% of doctors engage in the practice.

“This is not a trend yet. And it's not a new concept,” said Mark Bard, president of Manhattan Research, a health care market research firm, who noted that doctors have for years sold medications directly to patients. (Older patients may remember getting little white envelopes filled with pills.) What's new are the dispensing machines, mostly stocked with generics, now found in some doctor's offices.

“The health care system has created a circuitous route for the distribution and administration of prescription drugs,” which adds layers of cost, said Mr. Stein of QuiqMeds, which currently does business with about 40 physicians and will soon begin a pilot program with Aetna.

By some estimates, about 20% of patients in general never get their prescriptions filled. With QuiqMeds, Glenn Hyatt, ACP member, an internist in Maple Glen, Pa., uses a touch screen to order a drug, and the machine dispenses a pre-packaged bottle of pills, along with labeling and safety information. A computer keeps track of everything, and the machine is stocked and maintained by the company. Mr. Stein points out that the QuiqMeds System allows for drug utilization review at the point of care, provides patient educational material and even monitors recalls and refills.

“It's really an incredibly simple system, and it's a very secure system. The learning curve is relatively short,” said Dr. Hyatt, who began dispensing drugs a year-and-a-half ago.

Another office-based prescription business, MedVantx Inc. of San Diego, offers what it calls a consumer medication management program. Physicians offer a 30-day sample of a given medication and patients can order more through the mail. Samples are provided to doctors at no charge, paid for by participating health plans, or in some cases drug manufacturers, said Susan Hogue, the company's director of managed care networks and clinical services. The company does business with 18 health plans in eight states. The approximately 2,300 physicians who use the system don't profit from it, Hogue said, but they benefit from “patient satisfaction.”

Tareq Abedin, ACP Member, an internist and pediatrician in Ashburn, Va., uses a dispensing system provided through Allscripts FirstFill, which is integrated into his electronic health record. He said patients in some cases pay more for the convenience of buying drugs from his office, depending on their insurance plan's co-pay, but he said some patients like avoiding a trip to the drug store. “If you're feeling sick,” he said, “you can get amoxicillin on the way out.”

He said the service “does a lot for our reputation … of really going the extra mile with the care we give.”