Physicians are under constant pressure to alter their prescribing habits--and new developments are adding to the force.

In the past few years, there has been tremendous negative publicity about pharmaceutical manufacturers' efforts to influence physician prescribing via "drug reps," or pharmaceutical detail salespeople. As a result, the Pharmaceutical Research and Manufacturers of America promulgated regulations that constrain what drug reps may do when they visit physicians' offices. For example, the representatives must combine education with an offer of dinner or lunch. Further, the medical profession continues to debate the ethics surrounding pharmaceutical "freebies." I consider this a tempest in a teapot. What ethical physician would alter his prescribing practices based on pens and sticky notes?

More recently, insurance companies are entering the game to alter physician prescribing habits. For example, earlier this year, as a patient, I received a letter from my insurance company suggesting that I ask my doctor to prescribe double the dose of my medication, so I could save money by cutting those pills in half with a pill cutter at home.

I was incredulous--such a policy is clearly not in the patient's best interest, but in the insurer's best interest. It might reduce the co-pay for the patient, but it definitely reduces administrative overhead and processing costs for the insurer. Worse, the practice may even hurt patients. Among the obvious dangers are that patients cannot necessarily cut pills exactly in half, the distribution of medication and binder is unknown, the effect of gastric absorption cannot be quantified, and patients may become confused and cut the wrong pills.

Another even less ethical practice was just brought to my attention. Some health plans are now offering physicians financial incentives to switch their patients from higher-cost to lower-cost drugs. One plan paid physicians to switch patients from Lipitor to a generic version of its competitor, Zocor. The physicians were paid $100 for each patient switched between Jan. 1 and March 31, 2007. Incentivizing physicians to switch a patient's medication distorts the doctor-patient relationship and should not be permitted. The only consideration should be prescribing the best medication for the patient's condition.

If two medications have an equivalent effect on the patient, then it is reasonable to factor cost into the prescribing decision. However, in the example above, the patient was not a consideration. Cost alone was the deciding factor, and the incentive failed to consider patient needs.

Finally, a colleague on the Los Angeles County Medical Association board recently showed me a letter that a health plan in California sent to its patients. It offered patients a free month of simvastatin if they convinced their physicians to switch them from Lipitor. Consequently, health plans are now incentivizing their patients to convince their doctors to change medications. This strikes me as wrong. It clearly undermines the doctor-patient relationship. We prescribe medications we think are best for patients, only to see them back in the office waving a coupon for a free month of medicine if we switch their prescriptions.

LACMA already has concerns with health plans exercising therapeutic substitution wherein a patient is dispensed a drug different than the one prescribed, but which the plan feels has equivalent effect. Clearly, the above examples take therapeutic substitution one step further--again for purely financial reasons. There is no discussion of what is best for the patient or how different medicines in the same class may have differing side effects, patient impacts, effectiveness or absorption.

Patient compliance is enough of a problem. We shouldn't have to worry about coupons further eroding the doctor-patient relationship, too.