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>The problem with a "netflix" model, is that doctors can currently prescribe anything, regardless of cost or efficacy Unknown to almost everyone in the US is t

>The problem with a "netflix" model, is that doctors can currently prescribe anything, regardless of cost or efficacy Unknown to almost everyone in the US is that if you are a Medicare patient, when you go to fill a Rx before the pharmacist fills the therapy, insurance software suggests cheaper generics to the pharmacist and requires the pharmacist to do the leg work of asking the doctor to change the Rx based on what the insurance company wants (ie the cheaper medication). So the question might be..why would a pharmacist do what the insurance company software tells them... or why would a doctor second guess their initial Rx at the request of an insurance company trying to minimize their costs? Because if the pharmacist/pharmacy doesn’t do what insurance says or if the doctor doesn’t do what insurance says, they get dropped from the insurance network.

patmcc 8y ago
While I agree insurance companies do harm, encouraging generics is probably a net benefit. Doctors, just like anyone else, respond to marketing, so they remember 'viagra' more easily than 'sildenafil' and write prescriptions accordingly. There's often no medical reason a generic isn't 100% suitable.
- will_brown 8y ago
  The insurance companies are not recommending generics because it’s cheaper for the patient...they do it because it’s cheaper for them. There are many reasons generics, especially in the case of Medicare patients with chronic conditions, are worse for a patient. Generally if you have a Medicare patientwith chronic conditions such as diabeties and/or high blood pressure, and their physician has successfully been managing their conditions using a name brand therapy, it’s not good practice to switch their therapy to a generic because it helps the insurance company. More importantly, it’s only the active ingredients in name brand drugs and generics that are the same. coloring agents, binders, etc... are different and those can have significant negative side effects. There is no shortage of examples of generics having worse outcomes in the case of chronic conditions. Also it’s not just the therapy the insurance is changing, they also change the quantity. So again say you are a Medicare patient with type 2 diabetes and your doc prescribed 30 day Rx so you come back for the doc to check your blood work between fills, insurance is demanding the doctor change the Rx from 30 days to 90 days, because they don’t want to pay for the additional doctor appointment/blood work. They are watering down care and interfering with doctor/patient treatments.
  - throwaway34241 8y ago
    Do you think cost should ever be a factor in patient care? Looking it up, generics usually cost 80-85% less than brand drugs. They are tested and contain the exact same active ingredients. Is it worth the patient and/or the insurance company paying 5-7x more to keep the coloring agents etc the same? I understand that sometimes it may make a difference, probably especially for things with complicated delivery mechanisms like time-release drugs, but in those specific cases the doctor can explicitly request brand if it's important. Usually the patient copays are substantially higher for brand drugs than generic ones. And the insurance company paying obviously isn't free money either, it's from premiums that people pay every month (and/or taxes). At least in the US, people often don't get medical care because of the expense, so anything that inflates the cost further can be expected to cause real negative health outcomes by pricing more people out. I agree it would be better to not change even minor things if a drug is working. But I think that problem would be better solved by (as a condition of drug approval) requiring companies to disclose coloring agents, binders etc to generics makers once the patent expires, so they can make the exact same drug that was used in the initial clinical studies, rather than overpaying for drugs by 5-7x.
    - will_brown 8y ago
      >Do you think cost should ever be a factor in patient care? Should the insurers costs be a factor in patient care? No. Should pharmacists be paid by insurers to contra to cold call patients and interfere with the doctor patient relationship? No. Should the pharmacists be financially incentivized to get patients to consent changes to therapies on the basis those changes lower insurers costs? No. Should pharmacists be forced to do the bidding of the insurers under threat of being dropped from the insurance network? No. Should doctors be forced to accept the insurers recommendations for changes to patient therapies under threat of being dropped from the insurers network? No. It’s great to lower patient costs...and that’s what insurers and pharmacists on hanging their hat on, as I said almost no one knows the reality of how and why it’s being done. It’s no secret insurance companies are dropping pharmacies and doctors who don’t play ball (it’s worse for a patient to lose their network of doctors than pay for name brand drugs if the doctor feels that’s in their best interest). It’s also no secret that insurance companies are consolidating the market (buying pharmacies, buys hospitals and buying doctor offices) and forcing thei patients to the insurance owned doctors/pharmacies. It can’t be ignored that patients are now often seeing a doctor owned by the insurer, filling their drugs at an insurance owned pharmacy...and decisions about patient care are made by the insurance company to lower their cost, not patient costs.
- munk-a 8y ago
  This surprised me a bit but generics are not always a de-branded version of a medication or the same formulation manufactured by a different company. Often times generic equivalents are different formulations (sometimes prior generation formulas and sometimes divergent formulas) that are considered to have the same effect. They nearly always do, but the weirdness of our stupid patent system means that sometimes they can have weird allergenic effects or (especially with neurological medicines that are less well understood) differing efficacy.
  - jjoonathan 8y ago
    And drug companies will stir this FUD so hard your head will spin.
  - GeekyBear 8y ago
    The inactive ingredients are different.
- mnm1 8y ago
  That's great, but in this case even the generic costs $450 to $950 for a typical two week to a month bottle. I can't imagine how much the brand name costs if the generic costs that much. There are some alternatives like blink health (I have no affiliation) that bring that cost down to about $45 by negotiating prices en masse, I assume. If that's not a broken system, I don't know what is. Clearly, these medicines could cost a lot less but they don't because companies' profits are more important than health in America. Or take genetic tamiflu (can't remember the name). $150 for one course. I'd rather risk the flu, which I recently have, than take it preventatively. Can't imagine how much that brand name costs either but it it's unaffordable even on an engineer's salary, what's the use of even having this drug? Even with my insurance it was over $110. What's the use of having insurance in that case? Still unaffordable. Still going to get sick. What a fucked up system.
vonmoltke 8y ago
> insurance software suggests cheaper generics to the pharmacist I have never heard of pharmacists using "insurance software". The pharmacy system requests coverage from the patient's insurance, and it is either accepted or rejected. Additionally, if there is a generic they just fill it, assuming the patient consents. In fact, pharmacists in many states are required to point out generic alternatives if they exist. > requires the pharmacist to do the leg work of asking the doctor to change the Rx based on what the insurance company wants (ie the cheaper medication) If a prescription requires modification, the patient is required to go back to their doctor. Pharmacists cannot just ask doctors for prescription modifications. Where are you getting these ideas from?
- ratling 8y ago
  NexGen will suggest generics when you have a script for a name brand. It’s not coming from the insurance company. Source: worked for RiteAid for half a decade.
- will_brown 8y ago
  From the Center for Medicare and Medicaid Services. But like I said nearly no one knows any of this. Go into any pharmacy and ask the pharmacist about “MTM” and gauge their reaction. Look at outcomesMTM they are 1 of the 2 dominate insurance software vendors. Again you can ask nearly any pharmacist and they have an outcomesMTM portal that feeds them automated recommendations on behalf of the insurance carrier. Some of the bigger pharmacies, like Wal-Mart, have even removed the MTM portals from the individual stores already and created nationwide MTM centers. I even know of one company who uses pharmacy students (for free) to do this work for the insurers. Here is another tidbit for every recommendation the portal gives the pharmacist the pharmacy gets a “tip” (ie monetary bonus) to forward that to the doctor and if the doctor makes the change the pharmacy gets another tip. The only reason the insurers link up with the pharmacists to do their dirty work instead of the doctors directly is the insurers can’t pay the doctors the way they pay pharmacists to do their work bc of anti kickback laws. >Pharmacists cannot just ask doctors for prescription modifications. Again try asking any practicing family physician, ask them how many faxes they get a day from pharmacies requesting they change the patient Rx.
jazoom 8y ago
In Australia pharmacists can automatically switch to the generics unless a doctor says they can't on the prescription. I am totally okay with that for almost all scripts I write because it's the same drug and it saves the patient money.
- will_brown 8y ago
  well you may not mind if a pharmacist changes your Rx from name brand to generic to save the patient a little money. But this is more of the pharmacist interfering with your relationship with the patient... So imagine you write a therapy, and the patient gets a call from the pharmacists to the extent: 1. Your Doc Wrote the expensive drug, but if you agree we can save you $x by contacting your doc and encouraging them to change it; 2. Your Doc only wrote a 30 day fill, do you want us to ask for 90 days? (Consider these are your sickest patients, only your patients with chronic diseases, so you probably give them 30 days on purpose to get them back into the office to check their blood). It may sound reasonable on its face but: 1. Your patient loses faith you are acting in their best interest; 2. It’s framed in a way that the pharmacist knows more than you; 3. It’s not disclosed to the patient or to you as the doc, that the pharmacy getting paid bonuses by the insurance company to do it; and 4. If you disagree with the request for change (it doesn’t matter why, it will harm your rating with the insurer and you will potentially be dropped from the insurance network and lose your patients with that plan/insurer).
  - jazoom 8y ago
    I wasn't at all saying the way it's done in USA is good. I was suggesting that making it allowed unless explicitly disallowed might be a better way to go.

patmcc 8y ago

While I agree insurance companies do harm, encouraging generics is probably a net benefit. Doctors, just like anyone else, respond to marketing, so they remember 'viagra' more easily than 'sildenafil' and write prescriptions accordingly. There's often no medical reason a generic isn't 100% suitable.

will_brown 8y ago
The insurance companies are not recommending generics because it’s cheaper for the patient...they do it because it’s cheaper for them. There are many reasons generics, especially in the case of Medicare patients with chronic conditions, are worse for a patient. Generally if you have a Medicare patientwith chronic conditions such as diabeties and/or high blood pressure, and their physician has successfully been managing their conditions using a name brand therapy, it’s not good practice to switch their therapy to a generic because it helps the insurance company. More importantly, it’s only the active ingredients in name brand drugs and generics that are the same. coloring agents, binders, etc... are different and those can have significant negative side effects. There is no shortage of examples of generics having worse outcomes in the case of chronic conditions. Also it’s not just the therapy the insurance is changing, they also change the quantity. So again say you are a Medicare patient with type 2 diabetes and your doc prescribed 30 day Rx so you come back for the doc to check your blood work between fills, insurance is demanding the doctor change the Rx from 30 days to 90 days, because they don’t want to pay for the additional doctor appointment/blood work. They are watering down care and interfering with doctor/patient treatments.
- throwaway34241 8y ago
  Do you think cost should ever be a factor in patient care? Looking it up, generics usually cost 80-85% less than brand drugs. They are tested and contain the exact same active ingredients. Is it worth the patient and/or the insurance company paying 5-7x more to keep the coloring agents etc the same? I understand that sometimes it may make a difference, probably especially for things with complicated delivery mechanisms like time-release drugs, but in those specific cases the doctor can explicitly request brand if it's important. Usually the patient copays are substantially higher for brand drugs than generic ones. And the insurance company paying obviously isn't free money either, it's from premiums that people pay every month (and/or taxes). At least in the US, people often don't get medical care because of the expense, so anything that inflates the cost further can be expected to cause real negative health outcomes by pricing more people out. I agree it would be better to not change even minor things if a drug is working. But I think that problem would be better solved by (as a condition of drug approval) requiring companies to disclose coloring agents, binders etc to generics makers once the patent expires, so they can make the exact same drug that was used in the initial clinical studies, rather than overpaying for drugs by 5-7x.
  - will_brown 8y ago
    >Do you think cost should ever be a factor in patient care? Should the insurers costs be a factor in patient care? No. Should pharmacists be paid by insurers to contra to cold call patients and interfere with the doctor patient relationship? No. Should the pharmacists be financially incentivized to get patients to consent changes to therapies on the basis those changes lower insurers costs? No. Should pharmacists be forced to do the bidding of the insurers under threat of being dropped from the insurance network? No. Should doctors be forced to accept the insurers recommendations for changes to patient therapies under threat of being dropped from the insurers network? No. It’s great to lower patient costs...and that’s what insurers and pharmacists on hanging their hat on, as I said almost no one knows the reality of how and why it’s being done. It’s no secret insurance companies are dropping pharmacies and doctors who don’t play ball (it’s worse for a patient to lose their network of doctors than pay for name brand drugs if the doctor feels that’s in their best interest). It’s also no secret that insurance companies are consolidating the market (buying pharmacies, buys hospitals and buying doctor offices) and forcing thei patients to the insurance owned doctors/pharmacies. It can’t be ignored that patients are now often seeing a doctor owned by the insurer, filling their drugs at an insurance owned pharmacy...and decisions about patient care are made by the insurance company to lower their cost, not patient costs.
munk-a 8y ago
This surprised me a bit but generics are not always a de-branded version of a medication or the same formulation manufactured by a different company. Often times generic equivalents are different formulations (sometimes prior generation formulas and sometimes divergent formulas) that are considered to have the same effect. They nearly always do, but the weirdness of our stupid patent system means that sometimes they can have weird allergenic effects or (especially with neurological medicines that are less well understood) differing efficacy.
- jjoonathan 8y ago
  And drug companies will stir this FUD so hard your head will spin.
- GeekyBear 8y ago
  The inactive ingredients are different.
mnm1 8y ago
That's great, but in this case even the generic costs $450 to $950 for a typical two week to a month bottle. I can't imagine how much the brand name costs if the generic costs that much. There are some alternatives like blink health (I have no affiliation) that bring that cost down to about $45 by negotiating prices en masse, I assume. If that's not a broken system, I don't know what is. Clearly, these medicines could cost a lot less but they don't because companies' profits are more important than health in America. Or take genetic tamiflu (can't remember the name). $150 for one course. I'd rather risk the flu, which I recently have, than take it preventatively. Can't imagine how much that brand name costs either but it it's unaffordable even on an engineer's salary, what's the use of even having this drug? Even with my insurance it was over $110. What's the use of having insurance in that case? Still unaffordable. Still going to get sick. What a fucked up system.

vonmoltke 8y ago

> insurance software suggests cheaper generics to the pharmacist I have never heard of pharmacists using "insurance software". The pharmacy system requests coverage from the patient's insurance, and it is either accepted or rejected. Additionally, if there is a generic they just fill it, assuming the patient consents. In fact, pharmacists in many states are required to point out generic alternatives if they exist. > requires the pharmacist to do the leg work of asking the doctor to change the Rx based on what the insurance company wants (ie the cheaper medication) If a prescription requires modification, the patient is required to go back to their doctor. Pharmacists cannot just ask doctors for prescription modifications. Where are you getting these ideas from?

ratling 8y ago
NexGen will suggest generics when you have a script for a name brand. It’s not coming from the insurance company. Source: worked for RiteAid for half a decade.
will_brown 8y ago
From the Center for Medicare and Medicaid Services. But like I said nearly no one knows any of this. Go into any pharmacy and ask the pharmacist about “MTM” and gauge their reaction. Look at outcomesMTM they are 1 of the 2 dominate insurance software vendors. Again you can ask nearly any pharmacist and they have an outcomesMTM portal that feeds them automated recommendations on behalf of the insurance carrier. Some of the bigger pharmacies, like Wal-Mart, have even removed the MTM portals from the individual stores already and created nationwide MTM centers. I even know of one company who uses pharmacy students (for free) to do this work for the insurers. Here is another tidbit for every recommendation the portal gives the pharmacist the pharmacy gets a “tip” (ie monetary bonus) to forward that to the doctor and if the doctor makes the change the pharmacy gets another tip. The only reason the insurers link up with the pharmacists to do their dirty work instead of the doctors directly is the insurers can’t pay the doctors the way they pay pharmacists to do their work bc of anti kickback laws. >Pharmacists cannot just ask doctors for prescription modifications. Again try asking any practicing family physician, ask them how many faxes they get a day from pharmacies requesting they change the patient Rx.

jazoom 8y ago

In Australia pharmacists can automatically switch to the generics unless a doctor says they can't on the prescription. I am totally okay with that for almost all scripts I write because it's the same drug and it saves the patient money.

will_brown 8y ago
well you may not mind if a pharmacist changes your Rx from name brand to generic to save the patient a little money. But this is more of the pharmacist interfering with your relationship with the patient... So imagine you write a therapy, and the patient gets a call from the pharmacists to the extent: 1. Your Doc Wrote the expensive drug, but if you agree we can save you $x by contacting your doc and encouraging them to change it; 2. Your Doc only wrote a 30 day fill, do you want us to ask for 90 days? (Consider these are your sickest patients, only your patients with chronic diseases, so you probably give them 30 days on purpose to get them back into the office to check their blood). It may sound reasonable on its face but: 1. Your patient loses faith you are acting in their best interest; 2. It’s framed in a way that the pharmacist knows more than you; 3. It’s not disclosed to the patient or to you as the doc, that the pharmacy getting paid bonuses by the insurance company to do it; and 4. If you disagree with the request for change (it doesn’t matter why, it will harm your rating with the insurer and you will potentially be dropped from the insurance network and lose your patients with that plan/insurer).
- jazoom 8y ago
  I wasn't at all saying the way it's done in USA is good. I was suggesting that making it allowed unless explicitly disallowed might be a better way to go.