Friday, October 31, 2008

Docs Stuck in the Middle

Big pharma encourages docs to prescribe the latest and greatest, high priced meds with incentives.

Carriers are also getting into the act by providing incentives to docs that promote generics.

Caught in the middle of this financial tug of war are the docs.

Most of the tactics used by drug manufacturer's (to encourage scripting higher priced meds) has been exposed for years. Now we find that carriers are using similar tactics to encourage docs to script lower priced drugs.

But is this such a bad thing?

Health insurance premiums are driven (like any other product or service) by the underlying costs associated with producing the plan. In other words, when the cost of health CARE increases, premiums rise by a corresponding percentage.

For example, when doctors pay more for office rent, salaries, benefits, equipment, med mal insurance, etc. they must bill higher rates to cover these increasing costs. In turn, the carriers who pay the docs for services rendered must raise their rates in a similar manner.

So what is wrong with a doc who is trying to "help the cause" by scripting lower priced meds?

Apparently a lot.

In Massachusetts, a pending bill would regulate incentive plans between insurance carriers and providers. A Michigan proposal would ban financial incentives in exchange for prescribing a generic medication

So politicians want to make it illegal for your doc to be compensated for scripting generics but say nothing about incentives from pharma for scripting higher priced meds.

Something is wrong with this picture.

In New York, state Sen. Jeffrey Klein introduced legislation that would prevent insurance companies from offering physicians incentives. A grandfather clause would require HMOs to continue providing brand-name drugs to patients already benefiting from it.

Many carriers and HMO's are waging their own battle on this front by moving higher priced drugs to upper tier copay's.

And the AMA is weighing in on this as well.

Last year, the American Medical Association warned that it considered the bonuses kickbacks and said doctors who accept payment from an insurer for switching a patient from a brand name to a generic drug could potentially face criminal and civil liability under federal statutes.

Criminal charges for trying to help their patients save money?

You have got to be kidding.

But never fear. Seems the AMA is playing both sides.

After 10 years of taking the cholesterol medicine Lipitor, which has no low-cost generic equivalent, Curran's new insurer under Medicare refused to cover it. They insisted he take the generic equivalent of a completely different drug and he was scared.

His physician, Dr. Mario Motta, gave him free samples of Lipitor provided by drug salesmen. He also wrote to the insurance company to explain Curran had tried generic drugs, but in this case the brand-name drug was essential.

Still the company refused to cover it. Curran started spacing out his medication out of fear he would run out. He wound up in the hospital and had a fifth stent put in to help keep his blood vessels open. The insurance company didn't relent until Motta got the American Medical Association to make a call.

That's even scarier than Halloween.

UPDATE: I'd just add that Bob's point about generics and cost efficiency is underscored by today's McPaper:
In fact, in what may well be the first documented case of a gummint program costing less than anticipated, Part D is on track to saving 12% based on its initially projected cost. HGS
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