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Going generic: Formularies limit brand-name choices


A patient with a complicated chronic skin disease consulted me some time ago. He had been under the care of another practitioner and was very satisfied with the quality of the care he had been receiving, but he could no longer afford the treatments being prescribed.

Key Points

This patient was covered by health insurance, but the formulary was somewhat restricted, and many brand-name drugs were not included. He was being given exclusively brand-name medications under the care of the other practitioner, and the cost of these drugs was several hundred dollars per month. He came to me not because I could treat his disease any more effectively; rather, he was looking for a more cost-effective treatment program.

To be sure, many financial problems in today's environment are out of the control of the physician. And most of us would find it very difficult to voluntarily cut our fees - which, incidentally, would have only minimal effects on the overall affordability of medical care.

I once had a discussion with one of the leaders of American dermatology and a person whose opinion I value. While discussing the use of biologic agents, she indicated that the costs associated with these agents do not in any way affect her decision to use them. Her only concern is that the management program she designs is the most effective for her patients. She leaves it to others to find the financial resources to pay for these expensive medications.

I strongly disagree with this notion. The interests of our patients are primary for us, but there is more to it than simply picking a drug that is effective for a given disease. We can often provide cheaper, but equally effective, therapy by prescribing generic drugs whenever possible.

Practitioner reluctance

It seems like such a simple concept, but there is great reluctance on the part of many practitioners to choose this route. Here are some of the arguments that have been made against the use of generic medications:

1. Generic versions of drugs are inferior to brand name medications. In fact, by law, generic drugs have exactly the same intended use, dosage, side effects, risks, safety and strength as the original medication.

I have heard countless times from physicians and patients that the generic version does not work as well as the brand-name drug. There is almost no data to support this notion.

2. There may be quality-control issues with generic drugs. The Food and Drug Administration closely monitors quality control and requires that generic agents be comparable in all ways to the brand-name equivalent sold in this country. And, as it turns out, approximately 50 percent of all generic products sold in the United States are manufactured by brand-name companies.

3. Generic drugs may have the same active ingredients as brand-name medications, but the vehicle-delivery systems in the brand-name versions (in the case of topical agents) are more elegant and effective. If there is data to support clear superiority because of this, very little makes its way into published articles in peer-reviewed journals.

4. Even if brand-name drugs are more expensive, the manufacturer's coupons offset the high co-pays that the patients endure. Firstly, this does not apply to the 48 million people who currently are uninsured in this country. Secondly, the coupons are a type of fool's gold. The patient starts out by paying less, but eventually, many of these coupon offers expire and the patients are back on the hook for a lot of extra money.

Lastly, on general principle, these coupon deals annoy me. Why can't drug manufacturers do what Wal-Mart does and give "everyday low prices" by dropping the cost of these medications to all customers? What is the magnitude of the difference between generic drugs and brand-name products? In some instances, the generic drug is not necessarily the best choice. An example would be topical fluorouracil. A 40 gm tube of the generic product costs $250; one brand-name competitor costs $415; but another comparable brand-name fluorouracil choice costs $180 for a 30 gm tube. However, there are many clearly less expensive generic versions of similar, if not, identical medications, as illustrated above.

As the lawyers like to say, res ipsa loquitor - the thing speaks for itself. We need to give our patients a break and prescribe the cheapest effective therapy that is available, including generic versions of medications, if possible.

In a small way, we can cut the cost of healthcare in this country. In a substantial way, our individual patients will be a little less likely to become impoverished by our actions.

Norman Levine, M.D., is a private practitioner in Tucson, Ariz.

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