November 30, 2013 | by Tami Dennis
Brand-name drugs are more expensive than generic drugs, that much is clear. What’s also clear, finds the independent, nonprofit newsroom ProPublica, is that a small percentage of doctors nationwide are prescribing what seems to be more than their share of the pricey versions – and Medicare is footing the bill.
“Just 913 internists, family medicine and general practice physicians cost taxpayers an extra $300 million in 2011 alone by disproportionately choosing name-brand drugs,” read the story “Medicare’s Failure to Track Doctors Wastes Billions on Name-Brand Drugs.” “These doctors each wrote at least 5,000 prescriptions that year, including refills, and ranked among the program’s most prolific prescribers.”
California doctors were among the top prescribers of such drugs, the Los Angeles Daily News points out. “Almost 65 million Medicare Part D claims totaling $7.5 billion were filed by internal medicine, family medicine and general practice physicians from the Golden State for their patients,” the newspaper reported.
Such headlines beg the question: Why would doctors prescribe more expensive drugs when clearly cheaper alternatives are available? The answer can be complex, as Cy A. Stein, M.D., Ph.D., the Arthur & Rosalie Kaplan Chair in Medical Oncology at City of Hope, explains.
“Generic drugs are sometimes not precisely equivalent to brand names," Stein said. "The drug substance (i.e., the molecule that actually does the deed) may be identical, but the formulation (i.e., the other materials in the pills, which may make up more than 90 percent of what the patient is actually ingesting), may be very different. This can lead to dramatically different rates of absorption in patients, and hence to diminished efficacy."
Then there's the matter of what is actually in the drug.
“The patterns of toxicity may also change due to different concentrations of drug and/or different release rates of the drug, in human beings," Stein added. "The rate of decomposition of the drug may change depending on what it is mixed with, leading to diminished efficacy."
Doctors are not compelled to prescribe brand-name drugs, but they may have had bad experiences with generics due to these types of problems and/or have had patient complaints, he pointed out. In such cases, prescription of the brand name can be a logical course of action.
"In fairness," Stein added, "there are no problems with most generics. However, if patients start to have problems, it is not unreasonable to look to the change in med, among other places, as the source."
When making a decision about whether to prescribe a brand-name or a generic drug, most doctors consider out-of-pocket costs, Stein said. Certainly, he does.
“I do try to control the cost whenever possible, especially when I think the generic and brand name are truly identical. Most of my patients can't afford some of these stratospheric prices.”
Stein, in fact, is currently working with Sumanta Pal, M.D., assistant professor of medical oncology and therapeutics research, to develop an affordable, and extremely powerful, drug combination for men with advanced prostate cancer. It combines smaller amounts of the high-priced drug Provenge with high-dose ketoconazole (HDK), with a hydrocortisone. HDK costs only a few dollars per month.
As for the potential ethical conflict that arises when doctors prescribe drugs manufactured by a drug company for which he or she has received speaking or consulting fees – another focus of the ProPublica reporting – that too is a complex issue that needs to be looked at case by case, Stein said.
“But in general, if it’s a question of brand-name drug 2213X versus generic 2213X, then, all other things being equal, which often they are not, then I would say it could be a conflict of interest.”
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