Physicians and Patients Views of Generic Drugs

1
Physicians and Patients Views of Generic Drugs

• John E. Billi, MD
• University of Michigan
• Health System

2
Generics Issues

• Patients concerns about generics - quotes
• Role of 2 or 3 tier plans
• is a copay a disincentive or cost sharing?
• DAW a morass
• Fought for it, yet poor value
• DAW insensitive
• The win-win rationale
• everyone benefits from better prescribing
• takes time to deliver the message to patients
• Pharmaceutical Benefits Managers - caution

3
UM Physicians report what their patients say
about DAW

• What I hear from my patients
• generics dont work for me
• I dont trust generics
• I read that generics are not the real thing,
  they are not pure
• why change something that is working?
• The most common thing I hear is "The generic
  form doesn't seem to work as well." Of course,
  after some probing this is usually entirely
  subjective, and gives me a chance to explain the
  differences between the two forms. Most patients
  are open to receiving generic forms once I have a
  chance to dialogue with them.

4
Physicians report what patients say about DAW

• I get this all of the time, predominantly for
  narcotic-based prescriptions. Although they
  dont admit this, the DAW version does have a
  significantly higher street value. Practicing in
  (X), Ive come to know this....
• Just the other day, a patient told me she had
  read an article about a generic manufacturer
  whose pills were not dissolving in the gut. She
  was certain quality control lapses or engineering
  flaws were more likely to be found in generic
  drugs and would now refuse all non-brand
  medications.
• I have found that the most common reason is a
  perceived lack of efficacy of a generic medicine
  in the past.

5
Physicians report what patients say about DAW

• In addition to intolerance or allergy
  arguments which are frequent, I hear from
  patients on certain chronic medications that they
  fear that generics are less reliable. Thyroid
  replacement and warfarin are two very common
  examples patients report having more difficulty
  stabilizing TSH and INR with generic preparations
  than with synthroid or coumadin. Ive also heard
  many of my colleagues express the same
  belief.NOTE MOST GENERIC SUBSTITUTION PROGRAMS
  ALLOW COUMADIN, BUT NOT SYNTHROID JB Others
  seem to feel entitled to brand names, and feel as
  if theyre being slighted if given a cheaper
  generic. I find this commonly among patients who
  feel a reason to mistrust. I will say that
  recent tiered copay structures seem to have
  dampened this. I now have many patients
  requesting generic medications to keep their
  out of pocket expenses down.
• For children, the brand name taste better.

6
Physicians report what patients say about DAW

• These comments are just from one afternoon of
  seeing patients at Briarwood Family Practice.
• Generics are just not as good.
• Generics never work for me.
• Please check DAW and write out dispense as
  written since I have the best insurance so I can
  have the best medication possible.
• On the opposite end
• Is there a generic for Premarin, the price has
  gone up so much I cant afford it anymore.
• Can we use generic since it will not be as
  expensive.
• Can we change to another drug that does come as
  a generic?

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Physicians report what patients say about DAW

• I recently had a patient in my internal medicine
  clinic say that he takes generics whenever
  possible, even if brand name alternatives are
  available. He says that he wants to save the
  health care system the extra money.
• In response to your request for DAW anecdotes - -
  I have taken care of at least two patients who
  have also stated "I am allergic to generics". I
  noticed that recently one of the large insurance
  companies has started an ad campaign with the
  slogan "Generics - the other brand name". Perhaps
  this will help all of us !

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Physicians report what patients say about DAW

• Conclusions
• Many patients distrust generics quality
• Many patients feel they earned brand coverage and
  so should use it (if not used, it is lost)
• Patients have been misled to believe brands are
  of great value, yet it wastes money better used
  elsewhere
• Physicians favor cost sharing (tiered copays) to
  engage patients financial interests

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Differential Copays and DAW

• Tiered copays have 2 goals
• cost sharing (like a copay)
• higher cost higher copay
• incentive to use lower cost drugs - a penalty
• DAW insensitive, tiered copay
• allows the physician to write DAW
• pay the brand copay regardless of DAW status
• rationale it is not a penalty, it shares cost
  - the brand drug does cost more
• benefit to all in lower future copay increases

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Dueling FormulariesHow many were going to St
Ives?

• Each patient has a payer
• Each payer has its PBM
• Each PBM has its PDL
• A doctor has to know each patients payers PBMs
  PDL to prescribe appropriately
• Or else -blocked at pharmacy
• calls, letters, faxes from PBM or pharmacy for
  preauthorization or switches
• higher copays for patients
• Poor profile
• RX HUB and palm formularies

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The All-Patient Solution

• Simple message for ALL patients and ALL
  physicians, regardless of coverage type Use the
  lowest cost, appropriate drug
• if uninsured, lowest cost drug is least for the
  patient
• if double or triple tier, has lowest copay and
  keeps open formulary keeps copays lowest for
  each tier
• if single tier, will increase likelihood it will
  continue, and limit future cost sharing
• This is the best way to preserve coverage for
  those who have it, and lower cost for those
  without.

12
Pharmaceutical Benefit Manager - Friend or Foe?

• Contracted by employers and health plans to
  maximize value of drug expenditures
• Receive majority of funding through
  pharmaceutical industry rebates, market share,
  educational programs, formulary loading
• Some are under federal investigation

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PBMs Serving Whose Interests?

• One PBMs performance drug list is 70 brand name
  drugs
• Their education promotes brand drugs
• COX 2, non-sedating antihistamines, SSRI, PPI
• If you eliminate their SSRI from your Preferred
  Drug List, then they eliminate the rebate for
  your most common statin (bundling)
• PDL determines tier 2 of a three tier benefit
• Letters to physicians with lists of patients
• on NSAIDs - consider COX 2
• on PPIs - switch to Nexium

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Improve Pharmacy Appropriateness Complex
problems sometimes require multiple approaches

• UMHS Preferred Drug List
• Developed by Ambulatory Formulary Comm.
  (physician, hospital, MCare)
• Based on drug class analyses by UM pharmacists
• Optimize costs, multiple HMOs Preferred Drug
  Lists (MCare, BCBSM)
• Available on web, CareWeb reference, palm,
  updated frequently
• Laminated cards (drug by payer) sent to all
  faculty/HOs, posters for clinics
• Academic detailing programs
• Pharm D from UM offer physicians to switch
  specific patients
• BCBSM savings-sharing pilot, Pharm D from BCBSM
• COX2, PPIs, statins, SSRIs, sinusitis drugs,
  generics, dose optimization
• Pharmacy Benefit Manager actions
• PBM hard edits for dose optimization COX 2
• BCBSM voluntary program encouraging generics and
  dose optimization
• House staff intervention plan from HO rep.,
  peer-to-peer, lunch
• Developing policy limiting pharm rep interactions
  further

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Improve Pharmacy Appropriateness Continued

• UM Campus changes all employees, retirees,
  dependents, 1/1/03
• Carve out pharmacy for all groups (HMO, BCBS,
  etc)
• Triple tier
• Campus Pharmacy Oversight Committee Advisory
  Committee
• Ban samples in UM sites
• New Sample Drug Policy adopted by ECCA 7/02
• Safety and JCAHO risk (inventory, lot ,
  expiration, instructions, recalls)
• Studies show samples influence prescribing
• Prohibited from long term use
• Indigent care pharmacy programs - coordination
  UM Pharmacy, Amb Care
• Vouchers for preferred drugs MCARE and BCBSM may
  fund generics
• Ambulatory Formulary Committee coordinates
  actions
• UM Pharmacy, GUIDES (Guidelines, detailing
  measurement), Inpatient PT, MCare PT, FGP
  Managed Care Committee, Medical Management
  Center, Campus carve-out

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Next Steps

• Communication plan
• Better specialist involvement
• in Preferred Drug decisions
• identify a faculty contact for each specialty for
  peer education
• Managing PBM conflict of interest
• Maximizing rebates is not the goal!
• ibuprofen to COX 2??? Prilosec to Nexium???
• New Policy pharmaceutical sales representatives