Kaiser Permanente bases its drug management process on three factors: the individual patient's clinical needs (as determined by the treating physician), evidence about comparative drug effectiveness, and cost (
+9). It conducts a careful, evidence-driven process to decide which drugs to include in its formulary. It has developed extensive educational programs, clinical guidelines, and decision tools about drug choices for physicians in the medical groups. But in its own view (
+9) "the most important formulary [management] element is the Permanente physician's ability to override and use a non-formulary medication if he or she feels that it is medically necessary for a specific patient."
For Permanente physicians, there is no prior authorization process for SSRIs. For example, if a physician wanted to prescribe sertraline as a first prescription for a patient whose twin had done poorly on fluoxetine but well on sertraline, the physician would simply have to write an exception code on the prescription. The patient would not have to make a higher copayment or wait for adjudication. The physician would experience no significant administrative burden. The process is hassle-free for both physician and patient.
However, the process is not one of unrestricted autonomy for the prescriber. Prescribing patterns are reviewed at clinical meetings. Discussion and debate occur regularly. As described by Robin Dea, M.D., who is chair of the chiefs of psychiatry for the Permanente Medical Group of Northern California, "We manage by education, peer pressure, and physician leadership, not rigid rules. We say, 'Here is how we want to do it,' but we understand that there will be exceptions. We use the power of influence rather than time-consuming procedures that take physicians away from patient care" (personal communication, August 2003).
Kaiser invests its managerial energy in increasing the use of generic fluoxetine in first-time prescriptions, but it does not seek to change the regimens of patients who are stable and doing well on nonpreferred agents. However, if a patient who was currently not taking medication but who had been successfully treated with one of the other SSRIs before the patent on fluoxetine expired developed a new episode of depression, a Kaiser Permanente physician would probably discuss the data on medication equivalence with the patient and ask whether he or she would be willing to use generic fluoxetine. If the patient was unwilling, the physician would be free to prescribe the original agent.