Rx vs OTC? Damned if you do,...

I'll stand on my head if that's what it takes to get meds into my patients' hands," says Andrea L. Skaggs, an FP in Lexington, KY.

Skaggs has been known "to write prescriptions for double or quadruple doses," so that patients can cut pills and-because most plans cover few if any over-the-counter drugs-to write a script to replace an OTC equivalent drug, "if that gains patients a financial advantage."

On that last matter-writing a script when there's an OTC drug available-Skaggs isn't alone. Although hard numbers are difficult to come by, anecdotal evidence suggests that many doctors across the country do much the same thing, without fear that they'll somehow be audited or get in trouble. (It wouldn't be cost-effective for plans to monitor doctors for such relatively minor infractions, says one expert.)

Doctors will also accommodate patients who do face copays. "Because the prescription might cost a patient a $10 or $20 copay but a similar OTC course of treatment would be more expensive, I've often prescribed NSAIDs and PPIs when similar OTC medications were available," says FP Heather C. Williamson of Bridgeton, MO.

Not every doctor is comfortable with such practices, though. "I'm always offended when a patient asks me to write an Rx for something that's available over the counter," says Abigail Hagler, an internist in Yuma, AZ. "In my opinion, it's insurance fraud."

Hagler may be overstating the case-but there's little doubt that, in helping out their patients, doctors are adding to insurers' costs, and, some would argue, gumming up "the system." "In effect, the practice allows healthcare dollars to be used for more expensive meds when there are cheaper ones available," says Margaret M. Davino, a healthcare attorney with Kaufman Borgeest & Ryan, in New York City.

Health plans have reacted in different ways. Some refuse to cover prescription drugs that have an equivalent OTC version. Others have begun putting the prescription versions of OTC drugs "into higher copay tiers, making the over-the-counter drugs cheaper," according to Michael H. Deskin, president of Pharmacy Benefit Management Institute, based in Tempe, AZ.

Still, in cases where a covered drug ends up costing less than an over-the-counter one, experts think that doctors have an ethical duty to put their patients first. "The doctor's job is to get his patient the best therapy for the least amount of money," says David Brushwood, an attorney and professor of pharmacy at the University of Florida College of Pharmacy, in Gainesville. "If the plan happens to have a silly rule"-no coverage for OTC medications-"the doctor's duty is to save money for the patient, not the plan."

Such a strategy might also prove cost-effective in the long run, points out Lorie Rice, who teaches a course in pharmacy law and ethics at the University of California, San Francisco School of Pharmacy, where she's associate dean for external affairs. Patients who don't purchase medications because they're too expensive sometimes end up in the hospital, says Rice. That raises a critical question for third-party payers: "Would you prefer to pay for a drug, even though it's available over-the-counter, or would you prefer to pay for a three-day hospitalization?"