Doctors complain about increasing reliance on generics: USA TODAY June 28, 2008

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Doctors complain about increasing reliance on generics

USA TODAY June 28, 2008

By Ray Finger, The ( Elmira , N.Y. ) Star-Gazette

More and more doctors believe that health insurance companies are taking medical decisions out of their hands by dictating the medications a doctor can prescribe to patients.

The physicians say they are often strong-armed by insurers who demand they prescribe generics by forcing patients to pay higher co-payments for brand-name prescriptions even when no generics are available — or by refusing to pay at all.

"They're (the insurance companies) practicing medicine without a license," said Dr. Gaden, who has a family practice in Kendall , N.Y. "They've never examined the patient. They don't look at their chart to see what other illnesses or problems they have," he said.

But insurance companies counter that they are following legitimate medical protocol developed by panels that include physicians.

And they say that without the pursuit of cost-effective treatment, prescription insurance coverage would be too expensive for employers to offer.

Doctors say they often must follow what is known as "step therapy," prescribing a series of generic medications first before being allowed to prescribe more expensive brand-name drugs.

The situation is more than a nuisance, said Dr. Francisco Corbalan, who practices internal medicine in Elmira , N.Y. Sometimes patients who have done well on medications for a long time are suddenly told by insurers that it is no longer covered, and they must change to another medication or it will cost them a lot more.

"I do get lots of requests from insurance (companies) directly to me to change the medication, sometimes bypassing the patient. I don't think it's right because the patient should know when I change his medication or her medication," Corbalan said.

In general, the changes that are made involve similar medications that work equally well and are tolerated equally well, so it usually works out for most people, he said.

"But there are a number of people for whom it doesn't work out as well, and it's very hard for them to get the medication that works," Corbalan said. "I understand the need to save money. I'm all for that, and I think we should try to do that as much as possible. But sometimes I think it's hard on the patient."

Beverly Hungerford of Kendall , N.Y. , one of Gaden's patients, is on 10 different medications and has struggled with insurance. Her insurance company insists that she use generics and refuses to pay for brand names, she said.

"I have problems with them," she said. "I have allergic reactions to them."

In some cases, Gaden said, there are different fillers and binders in generics that react differently with people's metabolisms and digestive tracts, so they might not get the full benefit of the medication, he said.

"The problem is, it's being pennywise and dollar foolish," he said.

The role of the insurance company is to provide access to health care at a reasonable cost, said Dr. Dubeck, chief medical officer and vice president of medical policy for Excellus BlueCross BlueShield of Central New York Southern Tier Region in Binghamton , N.Y.

"We are not in the practice of medicine. We provide health care insurance under a contract, and we administer that contract," he said.

The reality is if insurers don't pay for something, the odds are that patients are not going to get it, he said. The other reality is if that something isn't done to control costs, the number of people without coverage is going to go up, he said.

Physicians often have no idea what the different costs are because they haven't done that kind of research, he said. They may have listened to a drug representative at lunch one day who was making a pitch, he said.

Another driving factor behind cost-control efforts: pharmaceutical companies marketing directly to consumers, said Rodgers, vice president of pharmacy for Independent Health in suburban Buffalo The industry spent $5.6 billion on direct consumer advertising last year, he said.

"You don't do that unless there's a return on investment," said Rodgers, who formerly was employed by Bristol-Myers Squibb.

N.Y. State Sen. Klein, a Democrat and the state Senate's deputy minority leader, issued a report earlier this year that outlined numerous restrictions placed on brand-name prescription drugs.

"Generics aren't bad if it works for the patient, and the patient can save some money," he said. "But in many, many cases when you're dealing with a specific class of drug, a generic just doesn't work, and it should be up to the doctor to decide whether or not which medication works best for their patient.

"We should, I think, uphold the relationship between a doctor and a patient. If a doctor says you need a specific medication, that decision should be made by a doctor, not some bureaucrat sitting behind a desk," Klein said.