How switching from brand name drugs to generics is sometimes absurd

I had an interesting exchange with one of our nurses recently about a long-term patient of ours.

The e-mails went something like this:

Got a fax from —-’s insurance that his Lipitor won’t be covered anymore.  They will cover simvastatin, lovastatin, and pravastatin.  Let me know what you want to do.
Charlie

He’s on darunavir, and all three of those statins are contraindicated because of drug-drug interactions. Rosuvastatin?
Paul

Checked with them — rosuvastatin needs prior approval, and will cost him a lot more, but less than Lipitor. I’ll get the paperwork ready.
Charlie

An hour or so passes, and then this:

What dose rosuvastatin?
Charlie

5 mg daily, thanks.
Paul

Another hour, and then:

Just heard from them — after all the fuss, they approved the Lipitor after all.  Seems they just wanted to waste our time.
Charlie

Hysterical.

Look, I get it that generics are usually more cost-effective than branded drugs.  And I understand that health care costs are wildly out of control, and one way of controlling costs is to use generics whenever they are safe and effective, which is most of the time.

But think about the absurdity of the above case.

  1. The insurance company is paying for this man’s antiretroviral therapy, so they must know he’s on darunavir.
  2. They nonetheless are suggesting he switch to a contraindicated generic statin drug.
  3. They initially refuse to continue covering a drug that is working well and that the patient has been tolerating for years, but grudgingly will cover a slightly cheaper alternative.
  4. They set up barriers to jump over and tunnels to crawl through (the “prior approval” paperwork) even though there’s sound evidence to back up the requested brand-name treatments.
  5. After the obstacle course is navigated successfully by our experienced nurse, they relent and say that they’ll cover the original prescription after all.

And here’s the best part:  The exact same thing happened last year with this patient — with the same insurance company!

Reminds me of the classic Monty Python “Cheese Shop” sketch, where the customer (John Cleese) methodically asks cheese shop guy (Michael Palin) for dozens of different cheeses — all of them unavailable. When Cleese asks at the end if they have “any cheese at all,” here’s the response:

No, sir, not a scrap. I was deliberately wasting your time, sir.

Paul Sax is the Clinical Director of Infectious Diseases at Brigham and Women’s Hospital. His blog HIV and ID Observations, is part of Journal Watch, where he is Editor of Journal Watch AIDS Clinical Care.

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  • MassachusettsPCP

    “The insurance company is paying for this man’s antiretroviral therapy, so they must know he’s on darunavir.”

    Not likely. The “checklist” people manning the phones/fax lines/on-line are unlikely to be medically trained, and unlikely to have a “smart” cross-checking system for interactions like pharmacies and doctors’ EMR uses. These people are in a separate corporate structure, with different goals and ideals, than people who do such mundane things as actually check the patient’s medications, potential interactions, and have the training to send you out those reports about polypharmacy and potential interactions in your elderly patients. Nay, these serfs are the medically untrained initial defenders against overutilization. Specifics are not known by them and must be relinquished by the doctor — er, I meant “provider” — upon command, but not before untrained Alicia gets her chance to get the bonus-of-the-day for keeping a modicum of wild hoardes of overutilizing “providers” from breaking through. Thank you. Drive thru (if you can).

  • ninguem

    And yet I get meddling letters from insurance companies about interactions and various perceived problems with medications……all the time.

    If the darunavir was paid by the same insurance, the insurance would be able to come to that conclusion on their own.

    They’ve got all these pharm-dees who just know so much more than physicians.

    They could do it. They choose not to do it.

  • Jeff Taylor

    Ah the cheese shop sketch. In these days of drug shortages, the van breaks down often.

  • Angela Caffaratti, MD

    It seems like many people are upset with doctors working part-time. But these situations happen all the time, effectively reducing physician’s time with patients to part time. Noone makes money on this except the insurance company that delays care, serving it’s stockholders. Also, these time wasters inspire doctors to leave medicine or work fewer hours. It is a viscous circle. This is a problem that needs attention badly.

  • Janet

    I always found asking for the pharmacist consultant and then making sure i got their name and license number helpful. When they would ask me why I wanted that info, I would tell them I would record it in the chart so the lawyers could find it if an adverse event occurred. If they were going to dictate care, then they should put their own liability on the line, not mine. Worked every time.

  • Cam

    But you can get lipitor as a generic… I’ve been on it for 15 years. So why didn’t the doctor just ask for atorvastatin? This article has nothing to do with the impact of using generics, merely the impact of doctors failing to ask for generics.

  • mzmd

    Lipitor is not generic in the US as yet. I believe it is going generic sometime this fall or winter, or so I hear.

  • MarylandMD

    Look, it’s really very simple: they **are** deliberately wasting your time! They want to make it a bit more difficult to prescribe name-brand medications, so the next time you start to prescribe Lipitor, you say to yourself, “Oh, it really is a hassle to prescribe Lipitor, so maybe I should try Simvastatin or Pravastatin instead…” If by using such interventions they increase the use of generics over name-brand by 5-10%, they will save millions of dollars. The drug companies would be stupid **not** to use an intervention that would bend the cost curve for these expensive drugs by even a little bit.

    In the end, we physicians just have ourselves to blame. Time and time again, I see my colleagues using Nexium instead of Omeprazole, Lipitor instead of Simvastatin, or Atacand instead of Lisinopril (and spare me the lectures about the infrequent circumstances when those choices would make sense, as I am talking about the majority of times when there is absolutely no logical reason to choose the name brand over the generic).

    Sometimes, if you want to see where the problem is, all you have to do is look in the mirror.

  • Angela Caffaratti, MD

    I mostly but not always use generics. When I use brand names, I try to give justification on the order. I get prior auths for generics too. About atorvastayin, every drug has a generic name but may not have a generic product available yet.

  • Susan

    Sounds like you are participating in a research study on provider reaction to arbitrary , contraindicated claims denials. So third party payers are striving to practice evidence -based profit enhancements.
    If patients elect third party payment for their medical expenses, why shouldn’t the burden of dealing with disputed claims fall on the patients?

  • mkf

    if you all want to generate some ideas on how to reduce the cost of health care, I’m sure the greedy, profit-enhancement-seeking third party payers would be all ears.

    Are they trying to make money? Yes. Just like doctors are. Just like the pharmaceutical companies are. Just like all companies are. Even not-for-profits do everything they can to keep costs low and income high. That’s the nature of a sustainable economic model.

    Hey, have you noticed that the profits for the third-party payers are considerably lower than the profits for the pharmaceutical companies? The Health insurance/Managed Care Fortune 500 organizations range from negative1% to 6.3% (profit as a % of revenue) whereas the pharmaceutical companies range from 1.9% – the only one lower than the HIGHEST third party payer – to 36.5%. But goodness knows we should get the insurers to back off the drugs!

    There are two ways to make money – increase revenue or cut costs. If the third party payers that you are so annoyed with did only the former and not the latter, you’d all be complaining about that. The current model is unsustainable and the only way to change it is to start reducing COST. Naturally that is going to necessitate some changes in behavior for one or more individuals. However, we can all see where the system is headed if no changes in behavior occur.

    It would be really great to see some alternative solutions to the cost problem rather than complaining that this is an arbirtrary attempt to “waste your time”. Thanks.

  • gzuckier

    speaking with a bit of experience on both sides of the conflict;
    the major insurers by now all have programs in place that recognize drug-drug interactions, as well as drugs that are counterindicated for a particular patient for other reasons; drugs that are being prescribed longer than the recommended duration, etc. etc. often these are extra cost buyups, but big customers usually get them. so, that would have been caught; but not until the patient tried to fill the script.
    as for the rest of it; the attempt to change a prescription that has been in place for a long time, the paperwork hassles, etc; yeah, no doubts. i don’t think it’s intended to drive use of generics, though, as distinct from the original nudge to prescribe a generic which is; the vast majority of scripts that come through these days are already generic in the first place. what it is, is just another example of the various disconnects between all the players in our overly complex healthcare “system”, where system is used to mean “big ball of mud”. I’ve personally experienced such failures of coordination and cooperation at all levels; between doctors and their hospitals, insurers and their captive mailorder pharmacies, hospitals and their dietiticians, even doctors and their patient appointment schedulers. They’re all infuriating at best, life-threatening at worst. For the record, I’ve also had experience with the Canadian system and my biggest gripes with it are exactly the same.