The Massachusetts gift ban benefits health insurance companies

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by Edison Wong, MD

With the recent proposal to repeal the so-called Massachusetts “gift ban” (more appropriately referred to as the “interaction ban”), I asked myself who stands to gain the most from such bans?

Is it the consumers or patients? Is it the physicians or their practices? Is it the federal or state governments? Nope. Sadly, it is the insurers who gain the most, at the expense of patients.

The argument for “interaction bans” is that generics will save money over name-brand medicines, which are being “unnecessarily” or “irrationally” prescribed. Aside from being unclear who is defining necessary or rational in this debate, what is forgotten is who wields the most influence over the decision to prescribe a medication. The public is convinced that it is the physician, and, actually, that would make sense. And more recently, savvy public relations campaigns and advocacy efforts have convinced legislators (and the public, so the advocates claim) that it is the Pharma rep that controls prescribing. In reality, it is the insurance companies.

Insurance company actuaries decide which drugs are on the formulary (what they will cover) and which one is a preferred name-brand medicine (cheaper co-pay), based on benefit-to-the-bottom-line calculations. (Ironically, some generics are not even on a formulary list and are NOT preferred over name brands.) Consequently, these decisions, which are based on the whim of the insurer, dictate whether a patient has access to a medicine, not their physician, and definitely not the Pharma rep.

Does an intelligent Congressman or Senator really believe that a patient will blindly order a name brand drug when generics are available? What would they do in that situation? Why would they think the general public will be so eager to accept blindly a costly name-brand medicine when money could be saved? Some of my patients have to decide to forgo either food or medications. I hope Congress members realize they lack proper info about the situation and correct their version of reality.

Any practicing physician can attest that it is extremely challenging to get a name-brand medicine for patients, even after generics have failed. First, the physician must justify their clinical decision to the insurer by documenting the diagnosis and every other course of therapy that has been tried. The paperwork, called a “prior authorization” (PA), requires hours of labor-intensive, uncompensated work.

If the PA is approved, which is not guaranteed, the patient must then fend off their friendly pharmacist’s attempts to convert them to the cheaper “almost the same” generic alternative. What is NOT mentioned is that the suggested alternative is a different molecular entity with different efficacy and different side-effects (therapeutic substitution), and more insidious, that the pharmacy stands to make more money on the alternative.

And only in my State, if all of these barriers are surmounted, are patients then denied the use of manufacturer discounts and rebates, which could offset skyrocketing insurance co-pays. Needless to say, the prescription calculus is far more complicated than portrayed.

Among all these competing forces, neither logic no evidence suggests that a patient walking into a physician’s office will end up with an unnecessary and expensive bottle of pills because of a Pharma rep. This hypothesis only holds true in the minds of idealistic social science researchers whose primary interest is proving their repeated claim that a pen with a name brand label will bias and overcome all other obstacles.

Sadly, the true issue at hand is that many physicians will not or cannot perform the extra work required to obtain a name-brand drug even when it is safer or will work better than a generic because of the extra time or staff involved with the myriad paperwork, a real cost-driver of health care.

So the next time you hear of the egregious cases of Big Pharma exerting their control by ‘wining and dining’ physicians, take a moment to consider who really stands to gain by the proposed solutions and whether patients have even been entered into the equation.

Edison Wong is a physiatrist practicing in Massachusetts.

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