by Charles Ornstein
and Tracy Weber
We talked to dozens of experts for our
Monday report on how Medicare is wasting hundreds of millions of dollars a
year by failing to look into doctors who disproportionately prescribe
name-brand drugs. They struggled to explain why some doctors wouldn’t routinely
pick cheaper generics.
Name-brand drugs are appropriate in certain circumstances,
they said: when there are no equivalent generics, when patients have side
effects or if they are particularly sensitive to slight changes in a drug’s
composition. But these factors should apply to only a small fraction of cases,
they said.
Here’s more of what they told us:
1. Dr.
Richard J. Baron, president and chief executive officer of the American
Board of Internal Medicine: “We’ve almost glamorized the doctor who uses the
latest, greatest, newest drug because that’s the person doing cutting-edge
medicine. We’ve glamorized that. I think a lot of people need to get together,
and are getting together, on the professional side of this to say, ‘We need a
different understanding of what it is to be a good doctor.’ ”
2. Dr.
Ashish Jha, professor of health policy and management
at the Harvard School of Public Health: “I have lots of patients who are like,
‘I want brand name drugs only,’ and I talk to them about clinical equivalence
and how I would personally take the generics and how I give it to my own family
and how it’s just as good. ... I think it’s an abrogation of responsibility to
say the patients in my community demand this.”
3. Dr. Joseph
S. Ross, assistant professor of general internal medicine at the Yale
University School of Medicine: “This is just a pervasive issue and it’s not
easy to change. Doctors think the same way. They think if a drug has been
approved, it must be better, it must be safer. Otherwise, why would it be
approved to be on the market? It’s just better than a placebo and is reasonably
safe.”
4. Dr. Alexander Gershman, a Los
Angeles urologist who prescribes disproportionately more brand-name drugs than
peers under Medicare. “It would be wrong to say to physicians, ‘You have to all
prescribe generics’ because I think this will tremendously limit the quality of
the drugs to the patients ... To me, I don’t even know how much the drug costs,
honestly. If I go to pick up some stuff from the pharmacy, like antibiotics, I
don’t even know how much it costs until I go to the pharmacy.”
5. Dr.
C. Seth Landefeld, chair of the Department of
Medicine at the University of Alabama at Birmingham: “I think there are very
few instances where name-brand drugs have been shown to be beneficial compared
to an equivalent generic. We should by and large be prescribing essentially the
highest-value interventions that we can, which means, generally, generics over
name brands.”
6. Dr. Walid Gellad, an assistant
professor of medicine at the University of Pittsburgh who has compared
prescribing in Medicare Part D to the U.S. Department of Veterans Affairs: “The
VA requires physicians to really back up their decisions for certain drugs.
Some Part D plans do that, but not all of them. It gets into this very
interesting discussion: Is medicine practiced better when physicians cannot
make unfettered decisions?”
7. Dr.
Joseph Newhouse, John D. MacArthur Professor of Health Policy and
Management at Harvard University: “I just don’t know that Medicare can
successfully educate physicians. I think it’s a feasibility question. Medicare
should conceivably introduce financial penalties for physicians who have
abnormally low generic prescribing rates, along the lines they’ve done with
other kinds of pay-for-performance measures.”
8. Dr. Gary Reznik, a Los Angeles
cardiologist who prescribes a high percentage of brand-names compared with
peers in Medicare: “A lot of elderly patients have learned to recognize
medications by their color and shape, rather than by their names. The fact that
generics can come from different manufacturers and the pills can be of different
shapes and color every month confuses them and adversely affects their
compliance.”
9. Dr.
Aaron Kesselheim, assistant professor of medicine
at Harvard Medical School: “Medicare first of all has no idea that this is
going on. These guys need to be sent to remedial medical school. They need to
be re-educated. It’s not hurting patients, but it’s
hurting society and they should realize that.”
10. Dr. Henry Yee, an Alhambra, Calif., cardiologist who also
prescribes a higher percentage of name brands than his peers: “I rarely worry about the cost. I worry
about what’s best for the patient. ... If a patient said, ‘My insurance does
not cover this,’ I would change to generic.”