E-DRUG: Some Doctors Cash In by Being Their Own Pharmacist
[Donald provides an example of doctor dispensing from the USA. Some readers
will be aware of similar practices in developing countries where patients have
to pay directly, not through a health insurance company.
Warning - long message. DB]
Here is another way that drug prices can be increased 10-fold, by violating a
classic prohibition against doctor-dispensing that was common until the early
Insurers Pay Big Markups as Doctors Dispense Drugs
[Copied below as fair use; please fix URL in browser if broken - moderator]
Donald W. Light
Visiting Researcher, Center for Migration & Development, Princeton University
Network Fellow, Safra Center for Ethics, Harvard University
Senior Fellow, Center for Bioethics, University of Pennsylvania
Insurers Pay Big Markups as Doctors Dispense Drugs
By BARRY MEIER and KATIE THOMAS
Published: July 11, 2012, NYTimes.com
When a pharmacy sells the heartburn drug Zantac, each pill costs about 35
cents. But doctors dispensing it to patients in their offices have charged
nearly 10 times that price, or $3.25 a pill.
The same goes for a popular muscle relaxant known as Soma, insurers say. From a
pharmacy, the per-pill price is 60 cents. Sold by a doctor, it can cost more
than five times that, or $3.33.
At a time of soaring health care bills, experts say that doctors, middlemen and
drug distributors are adding hundreds of millions of dollars annually to the
costs borne by taxpayers, insurance companies and employers through the
practice of physician dispensing.
Most common among physicians who treat injured workers, it is a twist on a
typical doctor?s visit. Instead of sending patients to drugstores to get
prescriptions filled, doctors dispense the drugs in their offices to patients,
with the bills going to insurers. Doctors can make tens of thousands of dollars
a year operating their own in-office pharmacies. The practice has become so
profitable that private equity firms are buying stakes in the businesses, and
political lobbying over the issue is fierce.
Doctor dispensing can be convenient for patients. But rules in many states
governing workers? compensation insurance contain loopholes that allow doctors
to sell the drugs at huge markups. Profits from the sales are shared by
doctors, middlemen who help physicians start in-office pharmacies and drug
distributors who repackage medications for office sale.
Alarmed by the costs, some states, including California and Oklahoma, have
clamped down on the practice. But legislative and regulatory battles over it
are playing out in other states like Florida, Hawaii and Maryland.
In Florida, a company called Automated HealthCare Solutions, a leader in
physician dispensing, has defeated repeated efforts to change what doctors can
charge. The company, which is partly owned by Abry Partners, a private equity
firm, has given more than $3.3 million in political contributions either
directly or through entities its principals control, public records show.
Insurers and business groups said they were amazed by the little-known
company?s spending spree. To plead its case to Florida lawmakers, Automated
HealthCare hired one of the state?s top lobbyists, Brian Ballard, who is also a
major national fund-raiser for the Mitt Romney campaign.
?I consider the fees that these people are charging to be immoral,? said Alan
Hays, a Republican state senator in Florida who introduced a bill to bar
physicians from dispensing pills that was defeated. ?They?re legal under the
current law, but they?re immoral.?
Physician prescribing works like this: Middlemen like Automated HealthCare help
doctors set up office pharmacies by providing them with billing software and
connecting them with suppliers who repackage medications for office sale.
Doctors sell the drugs but they do not collect payments from insurers. In the
case of Automated HealthCare, the company pays the doctor 70 percent of what
the doctor charges, then seeks to collect the full amount from insurers.
The number of doctors nationwide who dispense drugs in their office is not
known and the practice is prevalent only in states where workers? compensation
rules allow for large markups.
Dr. Paul Zimmerman, a founder of Automated HealthCare, said that insurers and
other opponents of doctor dispensing were distorting its costs by emphasizing
the prices of a few drugs, rather than the typical price spread between
physician- and pharmacy-dispensed drugs.
Both Dr. Zimmerman and physicians who sell drugs also said the workers?
compensation system was so bureaucratic and complex that an injured employee
could wait days before getting a needed medication through a pharmacy.
?We did not institute this because of the money,? Dr. Marc Loev, a managing
partner of the Spine Center, a chain of clinics in Maryland, testified last
year at a public hearing in Baltimore. ?We instituted it because we were having
significant difficulty providing the care for workers? compensation patients.?
The loophole that raises the price of physician-dispensed drugs often involves
a benchmark called ?average wholesale price.? The cost of a medication
dispensed through a workers? compensation plan is pegged in some states to that
benchmark, which is supposed to represent a drug?s typical wholesale cost.
But doctor-dispensed drugs can undergo an ?average wholesale price? makeover.
It happens when firms that supply doctors with medications buy them in bulk
from wholesalers and repackage them for office sale. These ?repackagers? can
set a new ?average wholesale price,? one that is often many times higher than
For example, in 2010, a physician associated with the Spine Center, Dr. Loev?s
practice in Maryland, gave a patient a prescription for 360 patches containing
a pain-numbing drug, lidocaine. The worker?s insurer was charged $7,304,
according to a copy of that bill provided to The New York Times by a lawyer,
Michael S. Levin, who represents insurance companies.
A similar number of patches dispensed by a doctor in California, which changed
its regulations in 2007, is about $4,068, according to the California Workers?
Compensation Institute, a research group.
Warren G. Moseley, the president of a company in Tulsa, Okla., Physicians Total
Care, that repackages drugs for office sale by doctors, said it charged
physicians $2,863 for 360 patches.
Dr. Loev, who uses Automated HealthCare?s services, declined to be interviewed
and did not respond to specific written questions from The Times.
Dr. Charles Thorne, a principal at Multi-Specialty HealthCare, another
Maryland-based chain of clinics that dispenses drugs, also declined to be
Dr. Zimmerman, the co-founder of Automated HealthCare, said that drug prices
are set by companies that repackage medications for office sales.
He added that Automated HealthCare referred doctors to about a dozen
repackagers. But the company has a relationship with one repackaging company
called Quality Care Products, based in the Midwest. The two firms have
exhibited their services together and jointly sponsor a charity golf tournament.
The president of Quality Care, Gene Gunderson, declined to be interviewed and
the company did not respond to written questions.
Data collected by Florida insurers who handle workers? compensation claims
shows that Quality Care supplies about 40 percent of the drugs sold by doctors
in the state, a market share three times as high as that of its closest
Robert M. Mernick, the president of Bryant Ranch Prepack, a company in North
Hollywood, Calif., that repackages medications for office sale, said he found
it extraordinary that lawmakers in other states like Florida and Maryland were
allowing such drug markups to continue.
?I see it as corruption,? he said. ?I think it is horrible.?
In 2010, Abry Partners, a private equity firm in Boston, bought a stake in
Automated HealthCare for $85 million. Officials of Abry also declined to be
interviewed for this article.
That same year, Florida lawmakers tried to clamp down on how much doctors could
charge for drugs. Automated HealthCare responded with a major lobbying and
spending campaign, focusing its efforts on state leaders like the president of
the Florida senate, Mike Haridopolos.
When the bill was reintroduced this year, Mr. Haridopolos declined to allow a
vote. The state?s insurance commissioner had backed the move, saying it would
annually save firms and taxpayers $62 million, a figure disputed by Automated
Mr. Haridopolos said he didn?t believe the bill had a chance of winning. ?It
seemed like a big political food fight,? he said.
Mr. Hays, the legislator who introduced the measure, said he found that hard to
believe. ?The strategy of the people that were opposed to this bill was to put
the right amount of dollars in the right hands and get the bill blocked,? he
said. ?And they were successful in doing that.?
A version of this article appeared in print on July 12, 2012, on page A1 of the
New York edition with the headline: Drugs Dispensed By Doctors Cost Insurers