American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, March 31, 2011

QD: News Every Day--Brand-name drug requests lead to less compliance, more costs

Patients are less likely to fill a prescription when the brand name drug is requested than a generic, even if the patients requested the brands themselves. Researchers studied the noncompliance rate among retail pharmacy customers to discover that "dispense as written" instructions led to 50% greater odds of not filling the script and billions in higher costs for patients and insurance.

The costs issues also affect Medicaid savings, according to a second study, since generic drugs could generate savings without requiring an overhaul to the health care system.

While every state has generic substitution laws, doctors can override them on the script and patients can do so at the pharmacy. Even though the conscious choice to select a brand drug might suggest willingness to take it, studies show it actually leads to less compliance.

Researchers studied 5.6 million prescriptions for more than 2 million patients receiving drugs through a pharmacy benefits manager from any pharmacy in January 2009. Claims were defined as physician-assigned dispense as written (2.7%), patient-assigned dispense as written (2%), or neither. Results appeared in the American Journal of Medicine

A majority of prescriptions designated as dispense as written by physicians were products for which no generic was available.

"It is interesting to observe that physicians request dispense as written frequently for single-source branded products, medications for which no generics could be automatically substituted," the authors wrote. "Physicians with a strong preference for branded medications may not be aware of whether a generic is available and may request the branded agent as a preventive measure. Alternatively, physicians may request the branded medication to ensure that pharmacists do not substitute a different medication in the class," even though therapeutic substitution isn't allowed without contacting the physician.

Most patient requests for the brand name were for multi-source brands, among patients 55 to 74 years of age, for maintenance medications, and almost exclusively at retail pharmacies.

Patients and their insurance plans, respectively, paid an average of $17.90 and $26.67 for generic medications, $49.50 and $158.25 for single-source brands, and $44.50 and $135.26 for multi-source brands. Authors noted that in the one month of their study, substituting generics for the multi-source brands would have saved patients $1.7 million and the health plans $10.6 million. Scaling that assumption upward to the 3.6 billion prescriptions filled annually, patients could save $1.2 billion annually and health system costs could save $7.7 billion.

Also of note:
--Older physicians were more likely to request dispense as written than younger ones, and patients age 55 to 74 years were most likely to receive physician dispense as written prescriptions.
--Specialists were 78.5% more likely to write brand-name scripts (P <.001). ---Among new prescriptions for chronic medications, physicians requesting brands (odds ratio 1.50, P<.001) and patients requesting brands (odds ratio 1.60, P<.001) were associated with greater odds that patients did not fill the prescription.
--Compared with oral antidiabetics, patient requests for the brand name were more common for ulcer agents (OR 6.1), hypnotics (OR 4.3), migraine medications (OR 14.4), contraceptives (OR 3.7), thyroid medications (OR 16.5), estrogens (OR 3.6), anticonvulsants (OR 4.8), anticoagulants (OR 4.5), and analgesics (OR 4.5) (all P<.001).

A second working paper released by the American Enterprise Institute analyzed 2009 Medicaid drug data and identified 20 multi‐source drugs in which the generic could generate savings.

In 2009, states’ Medicaid programs paid $329 million more for brand names when alternatives were available, according to the report. Total spending on these 20 drugs was approximately $1.5 billion, so Medicaid overspent by 22% ($1.5 billion versus $1.17 billion). While Medicaid is a joint federal‐state program, the federal share is generally about 57% of the total.

Overspending in 2009 attributable to drugs with generics launched in 2008 totaled $142 million, the report said. Overspending from products with generic launches during 2009 totaled $94 million ($129 million on an annualized basis, given that the generics launched in 2009 were not available for the entire year). Thus, nearly three‐fourths of total identified waste is for spending on drugs with generic launches during or after 2008. However, there are important exceptions to this observation, such as Flonase and Duragesic, which have faced generic competition since 2006 and 2007, respectively.

Ten more drugs go off-patent in the next two years: Actos, Combivir, Concerta, Lexapro, Lipitor, Plavix, Seroquel, Singulair, Xopenex, and Zyprexa. Assuming that substitution rates are 70% to 80% and that the generics are half the price, Medicaid programs could overspend by $289 million to $433 million.

"The approach of a significant 'patent cliff,' when many blockbuster brand drugs will begin to face generic competition upon losing patent protection in 2011 and 2012, makes the likely future overspending in this program even greater if new policies are not promptly adopted," wrote the author.

The report also noted:

--Among the 20 drugs studied, Medicaid spent an average of $95 more per prescription.
--Most of the overspending (85%) was concentrated in eight identified chemical compounds, for which states spent roughly $279 million more.
--The greatest total amount of unnecessary spending was in the larger states of California ($102 million), Texas ($31 million), Georgia ($25 million), and Ohio ($21 million). The smaller states spent more per person, Vermont and Iowa ($31 per enrollee in each state), Maine ($18 per enrollee), and New Hampshire ($17 per enrollee).

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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