It's a medical decision, stupid.

January 28, 2008 9:09 AM

Someone is offering doctors a financial inducement (premium? kickback?) to write prescriptions for certain drugs at the expense of others. Only this time it's the insurers paying $100 a pop for switching patients from brand-name statins to generics. Pfizer, manufacturer of the statin Lipitor, the world's best-selling drug brand of all time, is pissed. They point to a study that says you are more likely to die if you switch to generic simvaststin than you are if you stay on Lipitor.

The study, funded by Pfizer, may well be total crap. It's basically a chart review, not a prospective experiment, and lacks predictive power.

...independent researchers say that limitations in the study, which was conducted by Pfizer’s own researchers, gives it little predictive power about what will happen to patients who take simvastatin instead of Lipitor. And they say the study is far less important than large clinical trials that have shown simvastatin’s effectiveness at reducing cholesterol.

“It will run counter to everything that’s been published to date if it’s true,” Dr. Lee said of the Pfizer study. He is president of the network of about 5,000 doctors in Partners HealthCare, the health system formed by Massachusetts General Hospital and Brigham and Women’s Hospital in Boston.

via.

Finally, for your infotainment, here's commentary on Doctor Robert Jarvik shilling for Lipitor in a series of ads for the super-ega-ultra-blockbuster.

posted by Mister_A (68 comments total)

that was super-mega-ultra....

and at 12 + billion dollars in annual sales, hardly an exaggeration.
posted by Mister_A at 9:13 AM on January 28

As much as I'd rather see people taking generics, I am 100% opposed to anyone inserting bribes between the patient and the doctor. This is unethical as hell.
posted by Nahum Tate at 9:29 AM on January 28

This is unethical as hell.

And the pharmaceutical companies have been doing it for decades.

Pfizer...is pissed

*weeps crocodile tears*
posted by mediareport at 9:32 AM on January 28 [1 favorite]

Thank goodness we have enormous corporations working to prevent doctors from harming us!
posted by DU at 9:32 AM on January 28

In this fight, patients will be the biggest losers (once again).
posted by Mister_A at 9:35 AM on January 28

There are also opinions on whether these drugs actually do anything to save lives
posted by Rubbstone at 9:36 AM on January 28

Yes, one of the great unmentionables about statins is the fact that most of their data look at the surrogate marker of changes in plasma lipoproteins, not at actual event rates (heart attack/death).
posted by Mister_A at 9:39 AM on January 28

I had always thought, as Nahum Tate suggests, that generics were a great alternative to overpriced brand-name drugs.

But some generics simply aren't as good as the originals, believe it or not. I take Synthroid for a recently-diagnosed thyroid problem, and there is dissension among medical professionals that the FDA method for establishing bioequivalence is not accurate enough:

Patients who take generic levothyroxine can, with each prescription refill, receive product from any one of the various manufacturers of generic levothyroxine. Since generic levothyroxine drugs do not have consistent potency from one manufacturer to the next, this introduces the possibility that with each new refill of medication, you will get a batch from a different manufacturer...one that is too potent, or not potent enough -- effectively delivering too much or not enough levothyroxine.

via, among others.

Knowing this, I specifically requested a Rx for Synthroid with "no generic" specified. The first two months went fine; this month, the pharmacy gave me a generic and said that they had contacted my physician, who okayed the substitution. Pffbbtt.
posted by misha at 9:44 AM on January 28

Pfizer should take some generic prozac.
posted by srboisvert at 9:45 AM on January 28

I am 100% opposed to anyone inserting bribes between the patient and the doctor.

In the future healthcare system, all bribes will be paid directly to the government.
posted by three blind mice at 9:45 AM on January 28

Some of my drugs aren't even available in generic. I've been suffering my full asthma symptoms for the last month because I can't afford Singuair (which my insurance company has decided in its infinite wisdom is experimental, ever since doctors started prescribing it for allergies,) and because the generic drugs- all mainly steroids- don't really help. I don't even want to start on the clusterfuck that is my non-generic, 22 dollar a pill and no more than 6 pills in a 45 day period Imitrex prescription.

I honestly, truly hope that the people who make these decisions end up with every fucking disease of which they're preventing a full and comprehensive treatment. And also, eyeball polyps.
posted by headspace at 9:55 AM on January 28 [4 favorites]

But some generics simply aren't as good as the originals, believe it or not.

Even leaving aside things like bioequivalence, there is published research on the placebo effect that shows that a significant number of people get better headache relief from branded medications. (Sorry, I'm too busy to look up the cite right now.)
posted by OmieWise at 9:57 AM on January 28

There was a similar decision out here when two health insurers (one the state employees plan) said they wouldn't pay for Lipitor until a doc could prove that generics or Crestor didn't work for the patient.

It made a number of people upset because of Crestor's notoriety in causing liver damage.
posted by dw at 10:00 AM on January 28

IvP: Insurance versus Pharma. Whoever wins, we lose.
posted by localroger at 10:00 AM on January 28

Some of my drugs aren't even available in generic.

You probably shouldn't switch then.
posted by biffa at 10:03 AM on January 28 [1 favorite]

Mister_A: Pfizer, manufacturer of the statin Lipitor, the world's best-selling drug brand of all time, is pissed.

The actual medical term is "pfizzed."
posted by koeselitz at 10:11 AM on January 28

Generics can sometimes be a big crapshoot, as our own personal experience with Wellbutrin generics has shown.

More concerning, really, than someone bribing doctors to write generic scripts (and, really, I don't know a doctor that doesn't automatically check the "Can substitute for generic" box anyway) is the growing move by insurance companies to force their customers into the insurers' own mail-delivery pharmacy programs (administered by 3rd party corporations such as Medco.

Our current insurer has unilaterally instituted one of these programs, cutting our normal prescription benefit every time we use a local pharmacy instead of their own program. Eventually, if you don't start using their program, you will end up paying full-price at your local pharmacy, with no insurance benefit.

Once you are in one of these programs, you lose any and all control over what quality of generic you are sent. This is important to us, personally, as our son takes the aforementioned Wellbutrin generics. The product from one particular manufacturer produces some quite severe adverse effects in our son, and we always shop around town among the pharmacies to see who is currently stocking the right manufacturers and who has the one brand that doesn't work. With the insurance company program, you simply do not have this level of control. You get what they send, end of story. Unfortunately, the offending brand of Wellbutrin generic also happens to be significantly cheaper than the other generics, and I have no doubt that price determines what we would be sent.
posted by Thorzdad at 10:14 AM on January 28

I'm not a doctorologist, but isn't simvastatin actually the generic name for Zocor, Merck's formerly patented cholesterol lowering drug? And isn't the generic Lipitor called atorvastatin, which is chemically different from simvastatin, and therefore not the same thing?

The drugs may or may not have the same efficacy, I have no idea, but this appears not to be the case where insurance companies are simply telling people to get the generic version of the prescribed brand name drug.

Maybe the FPP poster knew this, but the post isn't clear.

I think what is actually going on here is that doctors are recommending one drug, but the insurance companies want people to get a different that just so happens to be generic.
posted by Pastabagel at 10:21 AM on January 28

Just to make my comment above more clear, there does not appear to be a generic version of Lipitor available in the US. The Pfizer patent on Lipitor is still in force.
posted by Pastabagel at 10:23 AM on January 28

Rubbstone and Mister_A, a newspaper article isn't exactly definitive, especially when compared to the medical literature. In fact, that article on the efficacy of statins sucked. The literature definitely shows reductions in mortality/MI for patients with acute MI, previous MI, and clinically proven CAD. As for primary prevention in patients with *only* hypercholesterolemia, I can even find articles on Ovid that show reductions in mortality and MI for those patients (see CLIP study in 2002 in Japan, using pravastatin aka Pravachol). It was just another hysteria-causing article.
posted by desiderandus at 10:24 AM on January 28 [1 favorite]

I think the drug companies lose the argument that they deserve to be able to charge exorbitant rates to recoup their R&D costs when they spend more on marketing than R&D.
posted by mullingitover at 10:24 AM on January 28

Differences in brand-name versus generic drug efficacy have been reported by reputable sources, but again, it's a case by case basis, depending on the drug and the generic manufacturer, just as Thorzadad points out. I believe it mostly boils down to
a) fillers which may cause adverse effects, as per Thorz's comment above,
and
b) differences in bioavailibility of the formulations, and where within the specified window of therapeutic efficacy each drug falls. A quick google came up with this article for cross reference/more explanation.

Tangentially... this made me wonder -- are there people out there who protest against getting generics *IF* they worked just as well? As in, people who like getting "brand name" drugs purely on account of fashion or trendiness? I could somewhat see this happening in the case of, for instance, alprozalam vs Xanax... drugs in which the brand name holds a certain notoriety.
posted by NikitaNikita at 10:32 AM on January 28

Can't insurers just pay the patient $100 if they agree to switch to the generic? Then docs can prescribe whatever they think works best, and the patient can decide if it's worth it to switch. This assumes the drug companies can offer to pay the patient to request their drugs, but can't not bribe docs either.
posted by Crash at 10:32 AM on January 28

I think the implication that doctors will take money in exchange for writing certain perscriptions is borderline libelous.
posted by Pope Guilty at 10:36 AM on January 28

Of course it's not definitive, desiderandus, but the data from the lipitor hypercholesterolemia trials do not show a significant reduction in CV mortality, iirc, they show reduction in LDL.

On the other hand, in the ASCOT trial, there was a striking reduction in CV and all-cause mortality among patients with hypertension and at least one additional risk factor. The ASCOT patient population is very different from the populations in the hypercholesterolemia studies; the ASCOT patients are at higher risk for CV events. So yes, patients like the ASCOT patients are likely to benefit from treatment with Lipitor, but the jury is very much still out on whether there is any benefit in lowering cholesterol in patients without additional risk factors.

Pastabagel: The insurance company in the story wants doctors to write scripts for cheaper drugs, because that will increase their margin. They want docs to write these scripts for economic, rather than medical reasons, and they are paying them to do so. There is no generic version of Lipitor, so they must switch to a different drug in the same class, generally simvastatin.
posted by Mister_A at 10:39 AM on January 28

Crash, if a doc writes you a script for Lipitor (atorvastatin), the pharmacy can only switch to a generic version of that drug, not another drug entirely. Since there is no generic atorvaststin, the pharmacist can not fill that script with anything other than Lipitor.
posted by Mister_A at 10:43 AM on January 28

You know how Lewis Black kind of flips out on stage? I'm having one of those moments now, only it's not an act. I am not a person prone to outrage, but what the fuck? Seriously, what the fuck?

Why is a system like this allowed to exist? There are so many things wrong with this that I literally can not begin to analyze them. I would have a stroke if I did, and how the fuck would insurance deal with news-induced brain-damage? Well they don't cover that.

I don't live in the US anymore. One thing I don't miss is this healthcare shit. My Advair is $30 per disc, my Ventolin is $6 per inhaler. WITHOUT insurance. Even if I were on the $400/month local wage here, I could afford that no sweat. Fuck this system.
posted by saysthis at 10:52 AM on January 28 [1 favorite]

They invented Lipitor to extend the patent on Zocor. There practically no difference between them.
posted by bhnyc at 10:53 AM on January 28

bhnyc: Lipitor (Pfizer) and Zocor (Merck) were competitors, until Zocor went generic. Generic Zocor is simvastatin, and it's much cheaper than Lipitor.
posted by Mister_A at 10:59 AM on January 28

hm, on second thought that's not quite correct. anyway here's a link comparing the two-
http://www.thestalwart.com/the_stalwart/2005/11/statin_showdown.html

"Pfizer's problem is that they missed their biggest target, a reduction in "major coronary events". The Lipitor and Zocor groups were indistinguishable."
posted by bhnyc at 11:00 AM on January 28

Can't insurers just pay the patient $100 if they agree to switch to the generic? Then docs can prescribe whatever they think works best, and the patient can decide if it's worth it to switch. This assumes the drug companies can offer to pay the patient to request their drugs, but can't not bribe docs either.

I think that insurance companies have been trying to do something like this already with lower co-pays for generics, but it has had limited success. I can see an argument that patients are likely to just trust whatever script their doc writes--after all, he/she's the one with the MD, and if a generic was appropriate then the doc would have brought it up--and so really changing the behavior involves targeting doctors. When it comes to something like our health, I think it's plausible that few people will press their doctor about whether a cheaper option is available, in large part because we don't really feel like we know enough about medicine to properly weight the trade-offs (if I save $10 on this prescription, does that mean I'M MORE LIKELY TO DIE?!? Or do I just get to keep $10?) I don't think that argument--that doctors should be the ones targeted, rather than patients--is without merit, if we accept at face value that generics are just as good as brand-name (although from above, sounds like there might be reason to believe they are not).

For what it's worth, the entire health care system is starting to move this direction, including government programs like Medicaid and Medicare. While this seems like a very hot-button example, is it really different from any program that pays a bonus to a medical practice or hospital for hitting certain targets in caring for patients? (For example, getting a bonus if a certain percentage of your patients have all their vaccines by the age of 2, or at least a certain percentage of your female patients have had a PAP smear in the prior 3 years, or a certain percentage of your patients with congestive heart failure are on an ACE inhibitor.) That's using money to try to get doctors to treat in a certain way, but people rarely call it a bribe; they call it "pay for performance" and it's seen as the potential magic bullet that will let us keep costs down while giving people better care. Win-win, if you will

I think that if generics do indeed have the problems that people are pointing out upthread--variations in efficacy, and so on--then this development is worth getting outraged about. I'm less sure that the idea of money being injected into medical decisions is on its face a terrible idea, though. To say that it's totally inappropriate for money to influence medical care seems like being in denial that the money is already there. The question is, if we're already paying doctors and hospitals and labs to provide health care, should we set up a system where they are encouraged to provide it a certain way?
posted by iminurmefi at 11:07 AM on January 28 [1 favorite]

Mister_A, my point is that statins *as a group* have been validated for primary outcomes (cardiovascular death, nonfatal MI, etc.) in primary hypercholesterolemia (see CLIP), using one of the weaker statins Pravastatin. Your issue with that seems to be that the same trials haven't been repeated with atorvastatin (Lipitor) all over again.
posted by desiderandus at 11:22 AM on January 28

Well, exactly, yes.
posted by Mister_A at 11:24 AM on January 28

More about CLIP, which I will confess that I did not know much about previously.

1. This was a trial in Japan - results may not apply everywhere
2. Inconcllusive at best on the subject of CV events. It appears that there was a lower death rate and CV event rate in the pravastatin "continued" group, but I don't see a P value, so probably not significant.
3. The trial design is not appropriate for drawing efficacy claims. You would really want a more rigorous prospective trial to make claims about outcomes. This trial may generate hypotheses, but the data aren't strong enough; this is little more than a chart review of a group of patients that took a certain drug at a certain time.


CLIP is just not the kind of study to hang an efficacy claim on. It's interesting, but it's just not a big deal.

I do not doubt that statins are good for some patients, but the jury is still out on whether they are good medicine in patients with high LDL and few other CV risks.
posted by Mister_A at 11:37 AM on January 28

This is actually a big deal, not so much for how it affects one big pharma company but for the dangers for patients. For many drugs there is little risk in taking the generic. However, for drugs which are taken daily and which must have tightly titrated doses the 80% to 125% bioequivalence range of a generic may just not cut it, especially if a patient is switched from a generic at one end of the scale to a different generic at the opposite end of the scale. The validity of these studies are also in question due to the fact that they only test the bioequivalence in a few dozen people. For time release drugs the release rates of the generic are often quite inferior to the brand name drug which can lead to spikes or dips in the blood levels of the drug. There is quite a push to legitimize generics to control costs, but I think the FDA is letting down the patients by not requiring stricter standards and testing. Cut the range to 90% to 110% and test hundreds not tens of patients.
posted by caddis at 12:06 PM on January 28 [4 favorites]

I am also not sure how this payment is legal under the anti-kickback laws.
posted by caddis at 12:19 PM on January 28

Good points, Caddis.

For time release drugs the release rates of the generic are often quite inferior to the brand name drug which can lead to spikes or dips in the blood levels of the drug.

This is exactly the issue with my son's generic wellbutrin. The manufacturer of the inferior generic (Teva, if anyone is interested) apparently uses a release mechanism that allows almost half of the available dosage to be released within the first couple of hours. This is for a 1-or-two-pill-a-day medication. The result is an incredible spike and then a sharp decline. In my son, this leads to a very severe increase in depression and anxiety. Some of the other available generics get the mix better, but none come close to the brand version.
posted by Thorzdad at 12:20 PM on January 28

I am also not sure how this payment is legal under the anti-kickback laws.

Ask a doctor what he thinks of the idea that he'd be willing to write prescriptions based on payments from people.

The answer will be along the lines of "Fuck off, asshole."
posted by Pope Guilty at 12:21 PM on January 28

What caddis said - the key difference isn't in the drug itself, but the stuff around the drug that affects how quickly or slowly or well it's absorbed by the body. Bioequivalence, given different binders or manufacturing steps, is a tricky thing. A generic drug is not guaranteed to dissolve at an equal rate to the original, or equally well under all conditions, but rather with a rate that is within a certain margin, on average.

Combine that with the fact that, at least with over-the-counter generics, the manufacturer does not have as much at stake, namely, the good name of their brand, if they screw up. Bayer is likely to care more about their aspirin than GenericCo, because all Bayer really has going for them, when it comes to aspirin, is their brand.
posted by zippy at 12:25 PM on January 28

Mister_A, responding to your points

1) You'll never see a slew of well-designed, relatively bias (read: big Pharma) free trials coming out of the U.S. owing to the poor quality of medical records in the U.S. and the major influence of big Pharma. The studies coming out of Canada, Europe, Japan, etc. will always be relatively better, especially since countries with socialized medicine tend to have better medical records, and have a better incentive to look at primary outcomes like mortality and cardiovascular events.

2 and 3) I don't know if you're right about CLIP, since I can't pull the whole article, just the abstract. And p-values are over-rated, as *clinical* significance matters just as much as *statistical* significance. Hence why confidence intervals are the new rage in medical teaching institutions, as they address both issues.

I won't know the validity of CLIP until I read the whole damn thing.

But after skimming a bunch of hyperlipidemia trials, it seems you're right on your claim. However, I can't really see cardiologists as the ones to blame. They never deal with patients who have isolated hypercholesterolemia, so they'll never do the studies. Other specialties have been far more loathe to embrace EBM (neurologists get tons of their stroke data from secondary outcomes in cardiovascular studies, which is plain pitiful), and in this case it would be primary practice docs at teaching institutions that would need to step up.
posted by desiderandus at 1:05 PM on January 28

Oh, and to clarify, there are tons of good studies by cardiologists on hypercholesterolemia in patients with cardiac risk factors, diabetes, etc. Hence why I see the cardiologists in a more favourable light here.
posted by desiderandus at 1:08 PM on January 28

The insurers and pharma companies are just pure greed.
There's a new wrinkle to my CIGNA prescription plan this year. In addition to only 50% coverage (a change from $20-$40-$60 coverage), drugs classified as maintenance medications are no longer subject to the $2000/year co-pay limit. So, that expensive antibiotic at $400/treatment only cost me $200 for about a month's supply. But medication I take regularly that lists at $1200/month will cost me $7200 this year and won't deduct from my co-pay.
posted by paddbear at 1:12 PM on January 28

desiderandus, I am not slamming cardiologists. The quality of medical records has nothing to do with the quality of prospective clinical trials, by the way. There is a big difference between observational trials like CLIP and prospective trials like ASCOT.

Re: cardiologists, you are correct, simple hypercholesterolemia is not really the domain of the cardiologist, but many if not most statin prescriptions are written for patients with few risk factors other than elevated LDL. Primary care providers write tons of scripts for statins.

Finally, I am not bashing cardiologists OR statins here. I am pointing out that far too many medical decisions are motivated by financial concerns.
posted by Mister_A at 1:23 PM on January 28 [1 favorite]

...drugs classified as maintenance medications are no longer subject to the $2000/year co-pay limit.

We saw something similar when we went through underwriting with GoldenRule last year. The final policy they presented to us did not include anti-depressant medications under the prescription coverage. Instead, anti-depressants were covered under the equally-absurd $2000 lifetime mental health coverage. And, by "covered", I mean that we could apply the full-cost of the meds to that lifetime limit. Once we hit that limit, we would go full-price, out-of-pocket for all anti-depressant meds.

Needless to say, we declined that policy.
posted by Thorzdad at 1:44 PM on January 28

Pope Guilty wrote:
I think the implication that doctors will take money in exchange for writing certain perscriptions is borderline libelous. reasonably accurate.

If a doctor thinks that both drugs are basically equal, they're exceptionally likely to prescribe the one that gives an incentive.
posted by Tacos Are Pretty Great at 2:00 PM on January 28

I am also not sure how this payment is legal under the anti-kickback laws.

caddis, this may look similar, but I don't think this is at all what anti-kickback laws are meant to remedy. Those laws are meant to prohibit a doctor from doing something like referring you to a certain specialist because the specialist pays them $100 for the referral. Or a doctor telling you that you have tonsillitis and referring you to a special tonsillitis care center, which he or she owns a significant stake in. To be a kickback, it would require your doctor telling you that you needed to be covered by insurance company X in order to get healthy again, and then taking $100 from the insurance company when you signed up. Or the makers of the generic drugs themselves paying a doctor $100 for every prescription switched to their drug.

This is more like a purchaser paying their supplier a bonus if they hit certain performance targets. It's complicated by the fact that the services a plan buys aren't received by the plan--they're received by a patient--but I think it's still ultimately a buyer-supplier relationship between an insurance company and a doctor. That's not to say that this particular performance target (replacing name-brand with generic drugs) isn't a bad one that will ultimately lead to worse outcomes for patients--and that's reason enough to overturn this particular target--but it's not a kickback in the traditional sense. Prohibiting all such transactions might be throwing out the baby with the bathwater; to the extent that health plans and the government health care programs can use such carrots to encourage doctors to treat all patients according to current best practices, it's a potentially good method for making people healthier, as well as curbing some really persistent disparities in health care (women having worse outcomes then men when they show up to a hospital with chest pain, or black patients receiving less-aggressive pain management, for example).
posted by iminurmefi at 2:01 PM on January 28

I've got to disagree iminurmefi. This is a kickback, in this case it's the insurance co. saying, "I'll give you a hundred bucks to write a script for a generic instead of Lipitor." It's a bribe.
posted by Mister_A at 2:04 PM on January 28

Tangentially... this made me wonder -- are there people out there who protest against getting generics *IF* they worked just as well? As in, people who like getting "brand name" drugs purely on account of fashion or trendiness?

Observations from working in a pharmacy:

1. People who are superstitious about generics. Generally elderly and xenophobic. They don't want drugs unless they're made in the yoo ess of ay by the original company.

2. Rich people who think that generics are cheap because they are going to be shoddy. They have the money to fork for brands. They don't want to stoop to medication that the masses get.

3. People who are convinced that the generic version is somehow making them ill or not working properly, but don't have anything to back it up. They demand generic Lotrel. When Lotrel went generic, the manufacturer just took the excess stock and repackaged them into amlodipine/benazepril bottles. Seriously, the pills still say Lotrel on them. This also applies to any drug that's currently being produced as a generic under the 6 month manufacturer exclusivity. Norvasc? Made by Pfizer. Generic Norvasc - amlodipine - made by Greenstone, Pfizer's generic company.
posted by pieoverdone at 2:04 PM on January 28

The brand name and generics in question aren't even the same drug, you see? It's not generic Lipitor, it's generic something else.
posted by Mister_A at 2:06 PM on January 28

Mister_A, just hypothetically, would you consider it a bribe if an insurance plan paid a doctor an extra $10 for every one of their patients over 65 who was given a flu shot every year?

I mean, that's another situation in which the insurance company is trying to influence doctors to act in a certain way that will ultimately save the insurance company money. I'm skeptical that constitutes a bribe, though.

I'm definitely not trying to defend this particular example of insurance companies paying doctors in an effort to encourage changing this particular prescription--it sounds like this sucks, based on the evidence above. I just think there's two separate issues here: (1) insurance companies giving doctors financial incentives to treat in a certain way; and (2) generics being preferred over brand name. I think number (1) is easy to wring our hands over, particularly when we get reflexively "argh evil insurance companies!!" but I'm not convinced it's always a bad thing--there may be some cases in which the interests of the insurance company in saving money and the interest of the patients in getting good care line up.
posted by iminurmefi at 2:26 PM on January 28

Don't worry Mister_A, I'm wasn't acting pissy on you, I was just irritated by the nytimes article's hysteria. And I agree with you that American health care is too driven by the finances and not by the medicine. That is quite a low move.
posted by desiderandus at 2:28 PM on January 28

Does anyone know if red yeast rice would work well to lower cholesterol?
posted by millardsarpy at 2:40 PM on January 28

As a diabetic, I have watched the cost of my insulin climb ever upward and I don't have the option of a generic equivalent. People who have to take maintenance drugs have no choice but to bend over and take whatever Big Pharma or the insurance mobsters wish to insert.

The problem is not that the insurance or drug companies have so much power; the real problem is that profit-driven healthcare is allowed at all. There is way too much incentive to cut corners and gouge consumers.
posted by Benny Andajetz at 4:15 PM on January 28 [2 favorites]

If a doctor thinks that both drugs are basically equal, they're exceptionally likely to prescribe the one that gives an incentive.

Bingo. In most cases, the incentive is to prescribe the brand name drug. Direct advertising to patients works, and pharmaceutical representatives do actually influence the way doctors prescibe. I don't see anything going on here that is any less ethical than any of the other crap that goes on in American healthcare.

For most of the prescribing I do in my practice, there usually are reasonable generic equivalents and I usually choose them, not because I give two shits about insurance companies, but because it's cheaper for my patients. In cases where there isn't a generic drug, there is still usually a drug preferred by the insurance company and again, I will prescribe that one because it's cheaper for the patient, as long as I think it will work well enough for them.

The problem, for me, is that trying to figure out what the cheapest drug for the patient is going to be takes a *very* significant amount of my time. Insurance companies seem to renegotiate prices with drug companies several times a year, plus new drugs go generic all the time, and now there's this whole new mail order pharmacy thing. It's very difficult to get up to the minute formulary info at the time I write prescribing (even ePocrates isn't updated often enough) I literally get dozens of calls a day from patients asking me to change from Celexa to Zoloft or from Crestor to Zocor. Or the dreaded: "Doc, my insurance company changed mail order pharmacies on me and they need you to hand write all 12 my prescriptions once again even though you did that for me 2 months ago."

My purpose in this rant, is that I find it interesting that someone somewhere had the thought to actually pay the doctor for their work administering this system that benefits no one but the insurance company stock holders. 2 months ago, I totaled up the amount of time I spent each day dealing with crap like this and it easily adds up to the amount of time I would otherwise be spending eating dinner with my wife every day. After January 1, I had a clinic meeting and instructed my staff not to take any more phone messages along these lines, instead the patient is instructed to make an appointment to see me. I mean hell, if I am going to miss dinner with my family and make a medical decision that could potentially harm a patient, shouldn't I at least be compensated for it? Of course, this annoys the hell out of my patients, but at this point, I really feel like its a problem between them and their insurance company, I am just trying to get by here.

Anyway, this is a really interesting article that I hadn't seen and this is great discussion. And I agree that, in the end, patients are the ones who are being hassled the most (as usual).
posted by Slarty Bartfast at 4:24 PM on January 28 [3 favorites]

I think the implication that doctors will take money in exchange for writing certain perscriptions is borderline libelous.

I am not a Doctor of Law, but I think for it to be libel it has to be false.
posted by TheOnlyCoolTim at 4:37 PM on January 28

Imagine a world where the doctor determines what his patients should take as a prescription... ah, I'm just being an idealistic fool here.
posted by clevershark at 5:28 PM on January 28

Mister_A, please also consider WOSCOPS and AFCAPS/TexCAPS before asserting the lack of data on primary prevention. In contrast to ASCOT, the cohorts in these studies (which used different statins by the way) were not high-risk patients strictly speaking but the benefit in terms of cardiac events and overall mortality was still statistically significant. Taken together along with what you may or may not choose to extrapolate from the secondary prevention data that is quite extensive, I find the data for class-wide effects fairly convincing. Moreover, with respect to primary prevention, the current guidelines for statin use from ATP III clearly lean toward the use of statins in patients with other high-risk features (as dictated by a > 20% 10-year Framingham risk of coronary disease), which reflects the weight of evidence drawn from ASCOT.
posted by drpynchon at 7:38 PM on January 28 [2 favorites]

Apologies if what I just said made no sense to anyone who doesn't have a subscription to Circulation. Look into it -- it's a real page-turner.
posted by drpynchon at 7:39 PM on January 28

Generics can sometimes be a big crapshoot, as our own personal experience with Wellbutrin generics has shown.

Wow. It's reassuring to hear I'm not the only one -- used Zyban for quitting smoking on two occasions and on the third (it truly works well if you actually stick with the meds, which I did not), I was prescribed a generic. Night and day difference in the experience of taking it. Reading the comments above, I'll have to ask others who claim unacceptable side effects whether they tried the brand name or the generic... the brand name was one of the most tolerable, consistent meds of its type that I've taken.
posted by VulcanMike at 9:31 PM on January 28

(Forgot to note, for those unfamiliar with the drug -- Zyban = Wellbutrin. Same meds, different purpose, different name.)
posted by VulcanMike at 9:33 PM on January 28

VulcanMike,
Just to add I've also found some of these comments personally reassuring.


I'm just going through a similar "night and day" problem (not Zyban, though), after being switched from a brand I know and tolerate very well - I have it prescribed very occasionally -to a generic - (pharmacist decision...)

It is a foul - and a very isolating experience.

I googled "generic brand [name of drug]" and "complaints" - because the name brand has only recently come off patent - and there are a vocal number of similarly miserable patients out there with the same confounding reaction to the generic.

It's certainly not a life-threatening situation - but it is vile.

(This is just a solidarity comment - as I battle on myself!)
posted by Jody Tresidder at 4:51 AM on January 29

to a generic - (pharmacist decision...)

Let me clarify something here. The pharmacist does not nefariously switch you do a generic drug on their own whim. If you look at the bottom of a script, you'll see two lines for the signature. One is 'Substitution Permitted' and the other is 'Dispense as written'. Say a doctor writes you a script for Prinivil and signs it sub permitted. The pharmacy is going to fill it with the generic lisinopril. 'Subsititution Permitted' is taken as 'fill as generic if available'. If you are hell bent on getting the brand, have the script signed 'Dispense as written'. The pharmacy cannot dispense any equivalent if that is the direction.

However, if you do specify brand when there is a generic available, your insurance company is most likely going to penalize you for it and it will cost you more. Don't bitch to the pharmacy staff, ok? Bitch to Anthem or UHC or whomever your carrier is.
posted by pieoverdone at 5:03 AM on January 29

"...Don't bitch to the pharmacy staff, ok? Bitch to Anthem or UHC or whomever your carrier is."

Point well taken, pieoverdone.

The pharmacist's decision in my case was entirely - I assume- because of the sub box being ticked.

However, it came as an unpleasant surprise to me since it was a regular scrip from the same doctor handed to the usual pharmacy. It must have been the first time the sub was inadvertently permitted - and it's all been undesirable.
posted by Jody Tresidder at 5:25 AM on January 29

However, it came as an unpleasant surprise to me since it was a regular scrip from the same doctor handed to the usual pharmacy. It must have been the first time the sub was inadvertently permitted

I'll use Norvasc as an example. It went generic in March of 2007. Let's say that you got a script for Norvasc in December of 2006. It's written for Norvasc with 11 refills, but is signed substitution permitted. That basically allows filling with a generic as soon as it becomes available. So when you get your refill in April, you're then getting the generic amlodipine. Signing sub permitted for brand drugs so that the generic can be dispensed when it becomes available is also done because as soon as a generic is available, your insurance company will expect you to fill it that way. If there are any scripts that are DAW and a generic becomes available while the script is still valid, we generally will call the doctor's office to get an ok on the generic fill. It's kind of hit and miss on the customer end of that. Some will be glad that we've proactively done that and saved them some money, so they are happy and the insurance company is happy. Others will piss and moan about giving them 'cheap chink made drugs'. Of course, then when we refill it for the brand, they piss and moan about how expensive it is. Rarrr. You can never win with crabby old people.
posted by pieoverdone at 5:59 AM on January 29

Here's a list of upcoming patent expirations.
posted by pieoverdone at 6:01 AM on January 29

Thanks drpynchon and slarty bartfast, great stuff. Looks like I've got some reading to do.
posted by Mister_A at 6:27 AM on January 29

As to dealing with elevated blood glucose levels, does anyone have an opinion as to the effectiveness of cinnamon and/or bitter melon?
posted by millardsarpy at 6:41 AM on January 29

As to dealing with elevated blood glucose levels, does anyone have an opinion as to the effectiveness of cinnamon and/or bitter melon?
posted by millardsarpy

I haven't had any changes with cinnamon. I have had great success with Januvia.
posted by paddbear at 6:49 AM on January 29