6 ms·

In every US state that I know of - a generic will be substituted for a brand name drug unless the doctor specifically specifies that it should not be.

by Aloha 9y ago

avar 9y ago
I was unclear, the podcast discusses cases where there's no generic version of the latest drug, and the latest drug is marginally more effective than whatever the latest generic is. So the generic just doesn't get considered, even though it would be suitable for the patient at much lower costs. This is unrelated to the situation you're describing.
- Aloha 9y ago
  Having a medical condition that requires long term medication maintenance - every single doctor I've had is very well aware of what is a generic and what is not - and tends to prescribe a generic, as they are often an ER version of the regular med, or a compounded version of two medications that can be taken separately.
  - cko 9y ago
    Former pharmacist here. I think most doctors do try to be cost conscious for the patient. But there are some who prescribe the newest and expensive brand name drug, and I can’t think of any reason why except some sort of incentive program. Many ophthalmologists will give the most expensive post surgical drops. When I called one to have him change it, he was like “uh, there’s no substitute.” I thought to myself, “then what did you guys do before these drugs came out a couple months ago?” Example: post cataract surgery people usually get an antibiotic, a corticosteroid, and an anti inflammatory. These generic drugs have been on the market for years. But new ones come out here and there that are hella expensive, we’re talking a copay of $5.00 vs $100+ per eye drop. Also there are prescribing guidelines called step therapy. For example for diabetes: https://emedicine.medscape.com/article/117853-treatment#d10 https://emedicine.medscape.com/article/117853-treatment#d10 doctors will skip the first few steps and prescribe a brand name drug immediately that’s like step 3. Insurance companies try to stop it by requiring authorization but... I feel like we’re fighting an uphill battle with perverse incentives.
    - refurb 9y ago
      In my former job, I talked to a lot of doctors about this stuff. What I found was that a lot of doctors look at the decision from a clinical lens only. Why not prescribe the latest branded product, even if it's only marginally better than the generic? Patients deserve the best, right? Making a cost vs. benefit trade off wasn't a universal process for many physicians.
    - darpa_escapee 9y ago
      I've actually run into a very similar example, I was prescribed a $400 dollar bottle of antibiotic eye drops, which my insurance fought and eventually paid for. I asked why that was chosen and if there were other options that I could pursue in the future. I was told that "these are your eyes and I'm not going to [fuck around] when it comes to your vision." I can't really disagree with that logic.
      - cko 9y ago
        True, but what did doctors do before these new drugs? “Fuck around” with “inferior” products... reason I’m cynical is because many new drugs that hit the market are not novel - for example loteprednol (older drug) vs difluprednate (newer): https://www.ncbi.nlm.nih.gov/m/pubmed/28628490/ https://www.ncbi.nlm.nih.gov/m/pubmed/28628490/ By the way, some of these newer drugs don’t have to be “superior” to be approved, they just have to be none-inferior to current therapy. https://www.raps.org/regulatory-focus™/news-articles/2016/11/when-can-non-inferiority-trials-establish-efficacy-fda-explains-with-guidance https://www.raps.org/regulatory-focus™/news-articles/2016/11...
        darpa_escapee 9y ago
        From what I gathered, it was more effective than the cheaper options, not that it was chosen because it was new and shiny.
cptskippy 9y ago
And drug makers are aware of this fact thus they incentivize doctors to specify the brand name drug.
- chimeracoder 9y ago
  > And drug makers are aware of this fact thus they incentivize doctors to specify the brand name drug. That's a bold and unfounded claim. Drug makers do not incentivize doctors to write DAW on a prescription.
  - cptskippy 9y ago
    > That's a bold and unfounded claim. Forbes and the New York Times have written articles on it. The Affordable Care Act has a provision that requires Doctors to disclose payments. Empirically, I dated a girl for about 2 years who was a sales representative for a major pharmaceutical company. When I asked about her job she said it was mostly dropping of brochures, swag, free lunches, and holding contests to promote products. Top producers (doctors) received all expense paid trips to medical conferences held in exotic locations or were invited to be paid speakers at said conferences. It was not too different from what the marketers did at the insurance broker I worked for at the time to cater Agents to write their lines.
    - chimeracoder 9y ago
      > Empirically, I dated a girl for about 2 years who was a sales representative for a major pharmaceutical company. When I asked about her job she said it was mostly dropping of brochures, swag, free lunches, and holding contests to promote products. Top producers (doctors) received all expense paid trips to medical conferences held in exotic locations or were invited to be paid speakers at said conferences. It was not too different from what the marketers did at the insurance broker I worked for at the time to cater Agents to write their lines. Your anecdote is about which drugs the doctors choose to prescribe. It has nothing to do with incentivizing doctors to prevent patients from filling generic versions of drugs and forcing them to purchase the brand-name version of the same drug, which is what this thread is about.
alistairSH 9y ago
There's a subtle difference between what you're describing and what the parent post describes. You are correct - in cases where there is a brand-name version of a dug AND also a generic version of the same drug, the generic is usually provided unless the brand-name is specifically requested. But, the parent post is describing cases where there is a new, brand-name drug that fills the same niche as an existing generic. Two different drugs, but often only slightly differing results. MDs often prescribe the newest, assuming it's better than the generic. MDs receive much of their ongoing education about drugs from the pharmaceutical sales reps, so they are bombarded with ads and samples (just as consumers are with ads on TV). As an aside, my dermatologist has been good about ensuring the costs of any treatments I receive are managed. She's recommended specific pharmacies, brand-name vs generic, and other tips/tricks to reduce the costs. This despite the fact that I don't directly bear any of the costs because I have a decent medical plan.
- LordKano 9y ago
  It sounds like your dermatologist is not just a good doctor but also a good person. Giving the same (high?) standard of care to patients without regard to their financial resources.
- ubernostrum 9y ago
  MDs often prescribe the newest That is not always a correct assumption. Due to the way some programs like Medicare pay out, doctors are sometimes strongly incentivized to prescribe the most expensive drug. Ophthalmologists are the usual notorious example, prescribing for macular degeneration. Medicare's reimbursement for drugs administered in-office includes paying the cost of the drug plus an additional percentage. For macular degeneration, research showed Avastin and Lucentis are basically equally effective. But Avastin is ~$50/dose and Lucentis is ~$2,000/dose. If you're going to get a "bonus" payment equal to a percentage of the cost of the drug, which one would you use? Lucentis has at times accounted for 10% of the entire Medicare part B drug budget because of this.
  - alistairSH 9y ago
    Wow! I didn't know about that quirk of the Medicare system. That's a pretty horrific incentive to overspend. My comment was based on the more typical situation, where the physician sends the patient to a pharmacist.
kbart 9y ago
"a generic will be substituted for a brand name drug" We had a similar corruption here, in Lithuania, until the law has been passed that pharmacist must offer a generic alternative. But there again, world is seen very differently in EU than USA, so I don't expect that to apply on the other side of the pond.

In every US state that I know of - a generic will be substituted for a brand name drug unless the doctor specifically specifies that it should not be.

by Aloha 9y ago

In every US state that I know of - a generic will be substituted for a brand name drug unless the doctor specifically specifies that it should not be.

avar 9y ago

I was unclear, the podcast discusses cases where there's no generic version of the latest drug, and the latest drug is marginally more effective than whatever the latest generic is. So the generic just doesn't get considered, even though it would be suitable for the patient at much lower costs. This is unrelated to the situation you're describing.

Aloha 9y ago
Having a medical condition that requires long term medication maintenance - every single doctor I've had is very well aware of what is a generic and what is not - and tends to prescribe a generic, as they are often an ER version of the regular med, or a compounded version of two medications that can be taken separately.
- cko 9y ago
  Former pharmacist here. I think most doctors do try to be cost conscious for the patient. But there are some who prescribe the newest and expensive brand name drug, and I can’t think of any reason why except some sort of incentive program. Many ophthalmologists will give the most expensive post surgical drops. When I called one to have him change it, he was like “uh, there’s no substitute.” I thought to myself, “then what did you guys do before these drugs came out a couple months ago?” Example: post cataract surgery people usually get an antibiotic, a corticosteroid, and an anti inflammatory. These generic drugs have been on the market for years. But new ones come out here and there that are hella expensive, we’re talking a copay of $5.00 vs $100+ per eye drop. Also there are prescribing guidelines called step therapy. For example for diabetes: https://emedicine.medscape.com/article/117853-treatment#d10 https://emedicine.medscape.com/article/117853-treatment#d10 doctors will skip the first few steps and prescribe a brand name drug immediately that’s like step 3. Insurance companies try to stop it by requiring authorization but... I feel like we’re fighting an uphill battle with perverse incentives.
  - refurb 9y ago
    In my former job, I talked to a lot of doctors about this stuff. What I found was that a lot of doctors look at the decision from a clinical lens only. Why not prescribe the latest branded product, even if it's only marginally better than the generic? Patients deserve the best, right? Making a cost vs. benefit trade off wasn't a universal process for many physicians.
  - darpa_escapee 9y ago
    I've actually run into a very similar example, I was prescribed a $400 dollar bottle of antibiotic eye drops, which my insurance fought and eventually paid for. I asked why that was chosen and if there were other options that I could pursue in the future. I was told that "these are your eyes and I'm not going to [fuck around] when it comes to your vision." I can't really disagree with that logic.
    - cko 9y ago
      True, but what did doctors do before these new drugs? “Fuck around” with “inferior” products... reason I’m cynical is because many new drugs that hit the market are not novel - for example loteprednol (older drug) vs difluprednate (newer): https://www.ncbi.nlm.nih.gov/m/pubmed/28628490/ https://www.ncbi.nlm.nih.gov/m/pubmed/28628490/ By the way, some of these newer drugs don’t have to be “superior” to be approved, they just have to be none-inferior to current therapy. https://www.raps.org/regulatory-focus™/news-articles/2016/11/when-can-non-inferiority-trials-establish-efficacy-fda-explains-with-guidance https://www.raps.org/regulatory-focus™/news-articles/2016/11...
      - darpa_escapee 9y ago
        From what I gathered, it was more effective than the cheaper options, not that it was chosen because it was new and shiny.

cptskippy 9y ago

And drug makers are aware of this fact thus they incentivize doctors to specify the brand name drug.

chimeracoder 9y ago
> And drug makers are aware of this fact thus they incentivize doctors to specify the brand name drug. That's a bold and unfounded claim. Drug makers do not incentivize doctors to write DAW on a prescription.
- cptskippy 9y ago
  > That's a bold and unfounded claim. Forbes and the New York Times have written articles on it. The Affordable Care Act has a provision that requires Doctors to disclose payments. Empirically, I dated a girl for about 2 years who was a sales representative for a major pharmaceutical company. When I asked about her job she said it was mostly dropping of brochures, swag, free lunches, and holding contests to promote products. Top producers (doctors) received all expense paid trips to medical conferences held in exotic locations or were invited to be paid speakers at said conferences. It was not too different from what the marketers did at the insurance broker I worked for at the time to cater Agents to write their lines.
  - chimeracoder 9y ago
    > Empirically, I dated a girl for about 2 years who was a sales representative for a major pharmaceutical company. When I asked about her job she said it was mostly dropping of brochures, swag, free lunches, and holding contests to promote products. Top producers (doctors) received all expense paid trips to medical conferences held in exotic locations or were invited to be paid speakers at said conferences. It was not too different from what the marketers did at the insurance broker I worked for at the time to cater Agents to write their lines. Your anecdote is about which drugs the doctors choose to prescribe. It has nothing to do with incentivizing doctors to prevent patients from filling generic versions of drugs and forcing them to purchase the brand-name version of the same drug, which is what this thread is about.

alistairSH 9y ago

There's a subtle difference between what you're describing and what the parent post describes. You are correct - in cases where there is a brand-name version of a dug AND also a generic version of the same drug, the generic is usually provided unless the brand-name is specifically requested. But, the parent post is describing cases where there is a new, brand-name drug that fills the same niche as an existing generic. Two different drugs, but often only slightly differing results. MDs often prescribe the newest, assuming it's better than the generic. MDs receive much of their ongoing education about drugs from the pharmaceutical sales reps, so they are bombarded with ads and samples (just as consumers are with ads on TV). As an aside, my dermatologist has been good about ensuring the costs of any treatments I receive are managed. She's recommended specific pharmacies, brand-name vs generic, and other tips/tricks to reduce the costs. This despite the fact that I don't directly bear any of the costs because I have a decent medical plan.

LordKano 9y ago
It sounds like your dermatologist is not just a good doctor but also a good person. Giving the same (high?) standard of care to patients without regard to their financial resources.
ubernostrum 9y ago
MDs often prescribe the newest That is not always a correct assumption. Due to the way some programs like Medicare pay out, doctors are sometimes strongly incentivized to prescribe the most expensive drug. Ophthalmologists are the usual notorious example, prescribing for macular degeneration. Medicare's reimbursement for drugs administered in-office includes paying the cost of the drug plus an additional percentage. For macular degeneration, research showed Avastin and Lucentis are basically equally effective. But Avastin is ~$50/dose and Lucentis is ~$2,000/dose. If you're going to get a "bonus" payment equal to a percentage of the cost of the drug, which one would you use? Lucentis has at times accounted for 10% of the entire Medicare part B drug budget because of this.
- alistairSH 9y ago
  Wow! I didn't know about that quirk of the Medicare system. That's a pretty horrific incentive to overspend. My comment was based on the more typical situation, where the physician sends the patient to a pharmacist.

kbart 9y ago

"a generic will be substituted for a brand name drug" We had a similar corruption here, in Lithuania, until the law has been passed that pharmacist must offer a generic alternative. But there again, world is seen very differently in EU than USA, so I don't expect that to apply on the other side of the pond.