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Medicare’s Failure to Track Doctors Wastes Billions on Name-Brand Drugs

The failure to track doctors who shun cheaper generics racks up huge costs for taxpayers in Medicare Part D, which fills one of every four U.S. prescriptions.

The doctor's office of Dr. Hew Wah Quon, one of Medicare’s top prescribers, in the Chinatown neighborhood of Los Angeles. (Patrick T. Fallon for ProPublica)

Versions of this story were co-published with Digital First Media websites and newspapers, with public radio station WNYC in New York and with American Public Media’s Marketplace.

Medicare is wasting hundreds of millions of dollars a year by failing to rein in doctors who routinely give patients pricey name-brand drugs when cheaper generic alternatives are available.

ProPublica analyzed the prescribing habits of 1.6 million practitioners nationwide and found that a tiny fraction of them are having an outsized impact on spending in Medicare’s massive drug program.

Just 913 internists, family medicine and general practice physicians cost taxpayers an extra $300 million in 2011 alone by disproportionately choosing name-brand drugs. These doctors each wrote at least 5,000 prescriptions that year, including refills, and ranked among the program’s most prolific prescribers.

Many of these physicians also have accepted thousands of dollars in promotional or consulting fees from drug companies, records show.

While lawmakers bitterly disagree about the Affordable Care Act, Medicare’s drug program has been held up as a success for government health care. It has come in below cost estimates while providing access to needed medicines for 36 million seniors and the disabled.

But this seeming fiscal success has hidden billions of dollars lost to unnecessarily expensive prescribing over the program’s eight-year history.

The waste is exacerbated by a well-meaning benefit written into the drug program, known as Part D: Low-income patients pay less than $7 per prescription regardless of a medication’s cost. The unintended consequence is that doctors can dole out name brands with little fear of pushback from patients about price.

Taxpayers spent $62 billion last year on Part D — more than a third of it on this low-income subsidy.

King of the Name Brands

Internist Hew Wah Quon of Los Angeles stands out as a high-volume prescriber of name-brand drugs. Only two of his top 10 drugs are generics. See the slideshow »

Dr. Hew Wah Quon is one of Medicare’s top prescribers. From a worn office in Los Angeles’ bustling Chinatown, he churned out $27 million worth of prescriptions from 2009 to 2011, data show.

All of Quon’s patients in 2011 qualified for the low-income subsidy, sometimes called “Extra Help.” He mostly prescribed name brands, such as AstraZeneca’s Crestor, for high cholesterol. Crestor costs more than $6 a pill; the leading generic costs as little as 20 cents.

If Quon had prescribed the way other internists do in California, choosing drugs so that his average cost was similar to theirs, he alone could have saved Medicare $5 million in 2011, ProPublica’s analysis shows.

“Boy, this doctor is a walking economic disaster,” said Dr. Jerry Avorn, a Harvard medical professor who has written about the risks and benefits of prescription drugs.

When first contacted by ProPublica last year, Quon defended some of his choices but abruptly ended the interview and has since declined to comment. Others who prescribe similarly said they believe name-brand drugs work better.

Health programs run by the U.S. military and the Department of Veterans Affairs control costs by strictly limiting the name-brand drugs doctors can prescribe. Some of the nation’s leading private health insurance plans do as well.

But Medicare, which pays for one in every four prescriptions nationwide, hasn’t asked Congress for the authority to put similar checks in place.

The Centers for Medicare and Medicaid Services (CMS), the federal agency that administers those programs, declined to make an official available for an interview and would not answer specific questions.

"By law, Medicare must cover items and services that are reasonable and necessary," a CMS spokesperson said in an email. "Within those rules, doctors and their patients are free to make medical treatment decisions that are best for the patient."

In the past, agency officials have said that while Part D is a government program, private insurers are responsible for running it. They normally decide how to manage their drug plans but cannot increase prices for the poor.

ProPublica’s analysis is part of a broader look at Part D oversight. An article in May found that Medicare has failed to take basic steps to investigate doctors who prescribe large quantities of dangerous, addictive or inappropriate medications.

Some, including the investigative arm of the Department of Health and Human Services, say CMS also needs to do more to stop waste — by investigating doctors who prescribe very differently than their peers. Others say it should establish penalties and bonuses to encourage more cost-effective habits.

“At some point, I think we have to hold prescribers accountable for their prescribing,” said Dr. Nancy Morden, an associate professor at the Dartmouth Institute for Health Policy and Clinical Practice, which has studied Part D. “I just don’t see how that’s different from holding them accountable for the quality of care in the exam room or in the operating room.”

Numerous studies show that generics, which must meet rigid Food and Drug Administration standards, work as well as name brands for most patients. Although some medications do not have exact generic versions, there usually is a similar one in the same category.

Many of the 900-plus primary care doctors who favored name brands shared another trait: Financial ties to the companies whose pills they prescribe.

Since 2009, 48 percent of them have received at least $1,000 for speaking, consulting and other promotional purposes, according to data ProPublica compiled from company web sites. Eleven have accepted $100,000 or more, the data show. Quon has received more than $7,000 in speaking fees and meals.

Among a random sample of doctors who prescribed generics more frequently, only 15 percent accepted drug company money, and the amounts generally were less.

Dr. Jeffrey Grove, a Florida physician who chooses generics 90 percent of the time for his Medicare patients, said it’s irresponsible not to consider cost.

“I don’t care that the government pays for it,” said Grove, president of the American College of Osteopathic Family Physicians. Grove was at the 2003 ceremony when President George W. Bush signed Part D into law.

“How many people could we insure that are uninsured right now if those physicians were practicing responsibly as well?”

King of the Name Brands

Quon’s office, right outside downtown Los Angeles, is wedged between a bank and a budget hotel. His name is half-peeled off the front window. On the waiting room walls, smudges mark where legions of patients leaned their heads.

Dr. Hew Wah Quon's name is half-peeled off the front window of his office in the Chinatown neighborhood of Los Angeles. (Patrick T. Fallon for ProPublica)

Yet in 2011, nearly 80,000 prescriptions flowed through this unassuming space and his other office in Monterey Park, a largely Asian city nearby.

Quon, 62, was the nation’s top prescriber that year for a dozen brand-name drugs and second-highest for another 13.

High on his list was Crestor, the most potent of a class of cholesterol-lowering drugs known as statins. Quon prescribed it 5,250 times — more than twice as many as any other doctor in Medicare. About 70 percent of his 948 Medicare patients filled a prescription for it.

Doctors typically find that generics such as simvastatin, the most-prescribed drug in Part D, work well to treat the risks from artery-clogging cholesterol. Crestor is usually reserved for stubborn cases because it costs 30 times as much.

Quon also liked Lovaza, purified and concentrated fish oil. It is marketed by GlaxoSmithKline to help reduce very high triglycerides, a fat in the blood linked to heart disease. At more than $90 per prescription in 2011, Lovaza’s price dwarfed that of over-the-counter fish oil supplements sold for a few dollars per bottle. Quon prescribed it 4,700 times, tops in the country.

Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic, said that while high triglycerides are a risk factor for heart attack and stroke, there is no scientific evidence that Lovaza lowers the odds of either event. Even GlaxoSmithKline says on the drug’s website that, “It is not known if Lovaza prevents you from having a heart attack or stroke.”

Nissen said it is “absolutely inconceivable” to treat so many patients “with a drug approved only to treat a relatively rare disorder.”

Another Quon favorite is Forest Laboratories’ Bystolic, which treats high blood pressure. He prescribed it 2,225 times, second-highest among Medicare doctors. Several drugs in the class, known as beta blockers, are generics and cost less than $10 per month. Each of his Bystolic orders cost $58.

The FDA has said Bystolic had no proven advantage over generic beta blockers. In 2008, it warned Forest Labs that its ads overstated the drug’s benefits.

Quon’s prescriptions for Crestor, Lovaza and Bystolic alone cost Medicare $1.3 million in 2011. Overall, his patients received name brands 75 percent of the time, compared to 23 percent for all California internal medicine specialists, including Quon. The average cost of Quon’s prescriptions was $129; the group’s was $65.

Medicare data show a consistent pattern for Quon since at least 2007.

“He is a big brand user. That’s his style,” said David Wong, whose C.T. Pharmacy is down the block. “He’s famous.”

The C.T. Pharmacy, where many of Quon's patients fill their prescriptions, in the Chinatown neighborhood of Los Angeles. (Patrick T. Fallon for ProPublica)

The prescribing habits of Quon and other primary care doctors with similar devotion to name brands collectively cost Medicare more than $1 billion in 2011. Nearly a third of that could have been saved if their prescribing had the same average cost as their peers.

Other specialties showed comparable patterns, but ProPublica’s analysis focused on primary care doctors because they treat a variety of illnesses and prescribe a range of medications that have generic alternatives.

In June, the HHS inspector general issued a report on potential waste and abuse in Part D. Among a group of “very extreme outliers,” the report cited one doctor with an “unusually large number” of Lovaza prescriptions whose costs in 2009 were 151 times more than average.

The inspector general did not name the doctor, but by matching statistics in the report to Medicare data, ProPublica was able to identify the doctor as Quon. No other physician met the criteria.

For the Poor, Priciest Pills

Part D was created amid a partisan fight over who should run the program — the government or private industry. But it was accepted that no matter who was in charge, poor Medicare enrollees would need extra help paying their drug bills.

Today, this special subsidy has ballooned into the program’s biggest cost, hitting $22.8 billion in 2012, according to the Medicare Payment Advisory Commission (MedPAC), a group that reports to Congress on Medicare. That's up 35 percent since 2007.

The growth has been fueled in part by the meager co-pays set by Congress.

 

Medicare Part D Totals by the Numbers, 2011

29M Beneficiaries with Part D Claims
1.2B Prescriptions (Including Refills)
$84.7B Retail Price of All Prescriptions
1.6M Number of Prescribers
39.7 Average Prescriptions per Beneficiary
$73 Average Retail Price of a Prescription
3% Portion of Prescribers That Wrote Half of All Prescriptions
4.4 Average prescriptions per patient, per provider

Note: Counts include initial prescriptions and refills dispensed. Retail price includes patients' out-of-pocket costs but does not reflect drug maker rebates.

 

For the more than 11 million who get the subsidy, generics cost no more than $2.65. Even the most expensive drugs cost the patients $6.60 or less.

Medicare reimburses drug plans for the difference between these amounts and what other enrollees pay.

With little incentive to be cost conscious, these patients and their doctors often use name brands when generics are readily available, studies show.

For others in Part D, typical co-pays for brand-name drugs — $40 to $85 — deliver a strong push towards generics, which generally cost less than $5.

A MedPAC analysis found that if low-income patients were prescribed generic drugs in the same proportion as other Medicare enrollees, the program could save $1.3 billion a year in just seven drug categories. A separate study this year by the Bipartisan Policy Center, a Washington think tank, says savings could be greater across the program, perhaps as high as $44 billion in a decade.

“I really think that you need both the carrot of lower cost for the generic side as well as the potential stick of higher costs on the brand side,” Bruce Stuart, then a MedPAC member, said at a meeting last year. Stuart heads the Peter Lamy Center on Drug Therapy and Aging at the University of Maryland School of Pharmacy.

Experts say that if patients had to pay higher co-pays for name brands, they would likely ask for something cheaper.

There’s no sign that the rules for Part D’s low-income subsidy will change anytime soon, however. Last year, MedPAC urged Congress to modify the co-pays to spur greater use of generics. President Obama proposed raising brand co-pays and reducing generic ones in his 2014 budget, but Congress hasn't acted on it — and likely won't.

 

 

Former CMS administrator Mark McClellan said encouraging greater use of generics makes sense. But faced with angering either the powerful pharmaceutical lobby or advocates for the poor, he said, lawmakers may see no political benefit in pushing a change.

The drug industry's leading trade group, the Pharmaceutical Research and Manufacturers of America, opposes higher brand co-pays for the poor. And the group has a history of batting away proposals that might cut into the billions of dollars of profits drug makers earn from high-margin products in Part D.

When Congress debated Part D in 2003, the group lobbied to kill a Democratic proposal to let the government negotiate volume discounts on drugs. In 2010, it helped squelch efforts to allow imports of cheaper drugs from abroad as part of the Affordable Care Act’s expansion of Part D.

Matt Bennett, a senior vice president with the group, called Part D a “success for both beneficiaries and taxpayers.” In a statement, he said, “Improved access to medicines in Part D not only leads to better health outcomes for patients, but it also lowers other Medicare spending."

It’s illegal to pay to doctors to prescribe, but the money drug makers give doctors to speak or consult on their behalf appears to be a good investment. In June, ProPublica reported that 17 of the top 20 prescribers of Bystolic, including Quon, received speaking fees in 2012 from the manufacturer, Forest Laboratories.

The pattern extends to Part D’s top name-brand prescribers. Two doctors, in Kentucky and New Jersey, have each received more than $225,000 in promotional payments from drug makers since 2009. A large chunk came from AstraZeneca, maker of Crestor, the doctors’ most-prescribed drug.

AstraZeneca spokeswoman Michele Meixell said the company doesn't choose its speakers based on prescribing but on “expertise in a therapeutic area, experience and qualifications.”

Part D’s Ethnic Hot Spots

Along one mile-and-a-half stretch of Los Angeles’ Koreatown, seven primary care doctors have some of the highest rates of name-brand prescribing in the country. Nearly 3,000 miles away in Brooklyn, N.Y., a single building in a Russian community houses six such doctors.

By mapping doctors who favor name brands, ProPublica found unexpected clusters in ethnic neighborhoods in and around the biggest cities. The average cost of a Part D prescription in these enclaves can be more than 50 percent higher than that of surrounding areas, the analysis showed.

Pockets of Doctors in Ethnic Communities Prescribe Drugs Very Differently Than Peers

Los Angeles

New York City

Name-brand prescribing among primary care doctors (internists, family practice, general practice), in Los Angeles and New York City, by zip code tabulation area. Only zip code tabulation areas with 10 or more providers shown. Note: Because Zip Code Tabulation Areas are the Census department's approximation of USPS zip codes, these counts are approximations as well. Download data.

To search for all providers in a zip code, enter it into the search box above. (For example, Los Angeles’ Chinatown.)

Researchers have previously noted regional differences in the way doctors prescribe drugs. But ProPublica's analysis aimed to unravel which individual doctors drive name-brand prescribing and what, if anything, they had in common.

Many worked solo or in small groups. Often they received their medical training outside the United States, records show.

Doctors’ drug choices can be influenced by many things — their peers, patient requests, a chat with a sales rep or studies in medical journals. In recent years, concern about undue influence has prompted many academic medical centers and large group practices to ban sales reps and to refuse free samples.

But many physicians in ethnic communities continue to embrace these relationships. When reporters visited offices in such neighborhoods of New York City and Southern California, drug reps crowded the reception counters as they unloaded rolling suitcases full of samples or waited to speak to the doctors.

Chinatown is one of the most densely populated parts of Manhattan. Outdoor fish markets crowd next to storefronts selling counterfeit handbags and pirated DVDs. Every block seems to have at least one pharmacy, and hundreds of medical offices are stacked above and around them. More than 90 percent of Part D prescriptions written in 2011 by these doctors were for the poor, Medicare data show.

 

 

The neighborhood is home to 20 high-prescribing primary care doctors who disproportionately favor name brands.

One of them, internist George Liu, is a founder and longtime leader of a prominent Chinese-American physicians’ association. In 2011, Liu wrote more than 9,000 prescriptions — 47 percent for name brands. By comparison, all internists in New York used name brands, on average, only 27 percent of the time.

Liu, who specializes in diabetes, said he does his own research on drugs and doesn’t depend on sales reps. A “new drug has a reason why it’s on the market,” he said.

Liu has given lectures for the makers of his favored drugs, he said. Three of his top 10 drugs are made by Eli Lilly, which has paid him $123,000 since 2010. One Lilly osteoporosis treatment, Forteo, cost Medicare $1,140 for a month’s supply.

Liu said scrutinizing how doctors use name brands is an "incorrect way of looking at medical care." He and his peers are saving Medicare money, Liu said, by staying open long hours and keeping patients from costly emergency room visits.

In an office nearby, Dr. Henry Chen praised Part D for making it easy for poor patients to get name brands. He said it’s wrong that state Medicaid programs for the poor and some private insurers force doctors to get prior approval before prescribing them.

Chen wrote more than 50,000 prescriptions in 2011, placing him among the top 100 prescribers nationally in Part D. Forty-five percent of his prescriptions were for name brands. He said picking a drug is like choosing how to get from New York to Washington.

 

 

“You could drive a Mercedes-Benz. You could drive a Rolls-Royce. Then you can drive a horse,” he said. All three would get you there, he said, “but the speed and the quality is different.”

Chen, who also has an office in Brooklyn, was paid $11,400 to deliver promotional talks for Eli Lilly and Merck last year. In 2011, he received more than $2,500 in meals from Lilly alone. Two of the drugs in his top 10 are made by Lilly and another by Merck.

Dartmouth researcher Morden said doctors in these areas are shifting the excess costs to others. “The other person one neighborhood over who’s getting a generic product is subsidizing the brand products for that whole neighborhood,” she said.

Not everyone in Chinatown defends such prescribing.

Dr. Perry Pong, chief medical officer of a local health center, was dismayed to hear that his colleagues stood out for pricey drug choices: “That’s bad. I’m ashamed of that.”

Pong said his center tells doctors to use generics first. But Medicare’s figures show some haven't done so, and Pong said he couldn't explain it.

‘The Light Bulb Goes Off’

Pharmacist Mark Greg mimics the time-tested tactics of drug company sales reps. Like them, he studies doctors' prescribing records, arms himself with medical studies and even provides lunch.

The difference: Greg is pushing generics.

He works for Advocate Physician Partners, part of a Chicago-area hospital chain that gives doctors bonuses for meeting performance measures that include generic use.

Greg, the group’s manager of clinical programs, asks doctors to see things from the patient’s point of view.

“Would you want to pay $10 a day for the same benefit as you would get for paying 10 cents a day?” he said. “In many cases the light bulb goes off.”

At one Advocate clinic in Chicago, 11 primary care physicians prescribed at least 80 percent generics in 2011. One of them, Dr. Tony Hampton, had an average prescription cost in 2011 of $41 — versus $89 among the 900-plus high name-brand prescribers in ProPublica's analysis.

Dr. Tony Hampton of Advocate Health reviews the medicine prescribed to Annie-Mae Valentine, 85, an elderly patient during a visit at the Beverly Medical Building in Chicago on Nov. 12. (Nathan Weber for ProPublica)

Hampton wrote more than 14,800 prescriptions in Part D, 13 percent of them for name brands. He said he gets very little resistance: “It’s just a few patients who need that little extra push.”

Across the country, private practices and government agencies have tackled the high cost of prescribing and determined that they can trim spending without sacrificing patient care. Some tightly control the drugs doctors can prescribe; others ramp up the co-pays on costly drugs.

Some with the lowest name-brand use have close ties to insurance companies, such as Kaiser Permanente and Southwest Medical Associates in Las Vegas, which is owned by UnitedHealth Group.

At both Southwest and Advocate, patients taking generics have met or exceeded national success rates for lowering cholesterol and controlling diabetes.

“You can be cost-effective and have high quality,” said Dr. Linda Johnson, medical director for primary care at Southwest. Johnson and others said only a small percentage of patients react negatively to slight fluctuations in their medications and require a name-brand drug.

Mitra Behroozi, executive director of the 1199SEIU Benefit and Pension Funds in New York, said her union’s health plan offers its 400,000 enrollees at least one option in each drug class, usually a generic, that is free. Members who want a name brand must spring for the difference, which can top $100 in some cases.

“We don’t pay for the latest, greatest if it’s not more efficacious,” she said.

The VA is likewise strict, often requiring prior approval for brands when generics are available. More than 80 percent of the 140 million prescriptions written annually by its doctors are for generics, said Mike Valentino, the agency’s pharmacy chief.

“We take out of the equation the marketing and advertising that drives so much of the prescription drug utilization in this country,” Valentino said.

The push has had a massive payoff.

Researchers have compared the VA’s prescribing to Part D’s. In a study that examined diabetes, cholesterol and blood pressure-lowering drugs, they found name-brand use under Part D in 2008 was two to three times higher than in the VA.

Medicare could have saved $1.4 billion if prescription choices mirrored those in the VA, according to the study, published in June by the Annals of Internal Medicine.

Lead author Dr. Walid Gellad, an assistant professor of medicine at the University of Pittsburgh, said that Medicare needs to follow the VA or create a system that tracks doctors and rewards or punishes them for their choices.

“There’s this big narrative that Part D has been this huge success because it’s come in under budget,” Gellad said. “My personal opinion is that we could have done a lot better.”

Tuesday, November 19th at 1 pm E.T. join reporters Charles Ornstein and Tracy Weber for a LIVE CHAT on their investigation into how Medicare's failure to track doctors wastes billions on name-brand drugs.

Download data of name-brand prescribing by zip code.

ProPublica’s Eric Sagara contributed to this report.

In my experience what is even worse is the great mark-ups by the drug companies which happens over and over each year.  I first noted this when reading my RX label and found that the price of 3 tablets of BONIVA was $499. My Pt D insurer paid part and I had a co-payment of $222! This is a commonly prescribed drug and is even available generically so this is obscene. My cost for a year is $888 so it doesn’t take too many prescriptions to reach the donut-hole, which I have and have not refilled the most expensive medication, which is the above.
My doctor prescribes generically so he isn’t the problem.

Skipp Lovejoy

Nov. 18, 2013, 4:33 p.m.

Article is right on the money. Sadly there are other “doctor problems” I have been subject too ... including double billing; not refunding over-payments to the doctor by the patient; doctors demanding payments for work already paid for by the insurance company; outrageous fees for really poor “doctoring”; encouraging the patient to have “operations” that they do not need; etc

Stephanie Palmer

Nov. 18, 2013, 4:49 p.m.

Some years ago, I had a prescription for Restasis for a mean case of dry eye. I had a prescription plan and paid just $7 for it - it was a month’s supply. When I read the receipt that my plan had saved me over $250 - that settled it. I couldn’t, in good conscience, use it. I gave it to someone else who also had the condition, and I found some over the counter stuff which cost me $14.  The entire Medicare Part D is an absurd giveaway of our tax money to big pharma. The fact that congress voted in favor of this deal leaving the government, i.e., us without any negotiating power is obscene. I refuse to take any of the new drugs; when they have side effects like “death seldom occurs,” or less critical bleeding, or may cause acne and beard growth if women are exposed.” You have got to be kidding. Congress should fix this, and they would if they were really concerned with our deficit. But they’re not; I call them the what me worry Congress. What a bunch of creeps.

I understand that there are physician abusers which always give an article like this the impression all physicians are fraudulent abusers. I don’t excuse the abuse, and ProPublica has turned up some problems which need addressing.

However, there is a difference between name brands and generics besides price.  Some patients simply do better on name brands than on generics.

However, I can tell you that my physician husband spends hours filling our Medicare Part D forms indicating why his patients need the name brand, and often times, patients are denied the exception to generics anyway, even when they really do need the generic.

Has anyone at ProPublica looked at the five page forms physicians need to fill out to get an exception for a generic?

Or tracked how many of these request forms go to an average clinic practice? Or how many hours staff spend responding to these forms? Or how much additional staff responding to these forms must be paid?

The real problem is not generics versus brand names.  It’s the pricing policies of drug companies.  There is no real excuse for the disparity in pricing. 

I reside near the Canadian border. Patients here regularly travel to Canada to buy their prescriptions.  Prescriptions the name-brand drug companies sell to Canada for wildly significant lower prices.

It’s often not the physicians, folks. It’s the monopolistic pricing allowed by the federal government. Are there abusers as noted in this article?  Of course.  But the underlying problem—why I can cross the border and buy the same drug by the same manufacturer in Canada for far less than I can in this country—seems to garner little attention.

I seem to remember that shortly after his first election, Obama had a secret meeting with big pharma; then work started on Obamacare.
We are all a huge herd of sheep who are lead regularly to be sheared.
God help us.

Check out the People’s Pharmacy May 15, 2013, FDA Fails to Catch Generic Drug Disasters report on how generics are not turning out to be as biomedically equivalent as they are supposed to be.  While there are issues for sure with pharmaceutical companies and doctors, generics are not benign and therefore not actually the simple answer to this issue.

I would like to see patients be more proactive and question the medications prescribed to them.  And ask if there are generics.  I am a member of Kaiser Permanente and am very pleased that they negotiate with drug companies and costs are so much lower than one would imagine.  Americans really need to educate themselves more.  Consumer Reports on Health would be a great publication for patients to read.

Paulette Green

Nov. 18, 2013, 9:13 p.m.

I have two issues with this story….one is the bashing of doctors who prescribe drugs that are non-generic…..and the other is the false assumption that all generics are created equal.

I’m one of those patients that’s been called out here…..low income medicare with Extra Help that has an expensive prescription that is not available as a generic but does have much less effective “substitutes”.  I have tried all the substitute drugs over the past 12+ yrs often with harrowing results.  And, once again because I have changed healthcare, I expect to be pushed by the healthcare provider into going through the tiers…..again.  Why can’t physicians orders for certain drugs be taken as gospel rather then having to go through this fight over and over again.  My last attempt at trying to change to a “formulary” drug had me afraid to go to sleep at night for fear that I would not awaken.

I do take another drug for another condition that is available as a generic but there’s two different manufacturers which produce different products with totally different effectiveness.  It took MY detective work to figure out what the problem was and to bring it to my physicians attention that the same prescribed drug can have different absorption depending on how the prescription is filled by which manufacturer.  I take an extended release drug for my diabetes but one manufacturer has a coating which does not break down within my system and is expelled just as it was taken…...yet another manufacturer’s tablet for the same drug, I have no problem with at all and my blood sugar numbers are within normal range.  Imagine my surprise when my mail order drug supplier informed me that they would only supply me with the one that doesn’t work…..despite the fact that my blood sugar went out of control because the drug is not broken down properly by my body!!

JoAnne Paolino

Nov. 18, 2013, 10:11 p.m.

I have been taking a cocktail of psychotropic drugs for the past 12 years, three of which are brand names. Of the three, two have generic counterparts. I tried the generics on different occasions and my symptoms reappeared shortly after I switched. Consequently,  I had to go back to the brand name drugs. Luckily my insurance covered the drugs until I became eligible for Medicare. Presently, I must subscribe to the most expensive Part D Rx Plan available in order to obtain the medications that are most effective for me. I absolutely agree with the previous writer: not all generics are created equal AND not all bodies absorb in the same way. Why don’t we have an investigative report on the differences in composition and absorption between generic and brand name drugs instead of blaming doctors who know the difference and who want to heal rather than mislead?

Paulette Green-
“Why can’t physicians’ orders for drugs be taken as
GOSPEL”?! Because we need a system of checks and balances, when some physicians are being paid hundreds of thousands
of dollars a year by Drug Manufacturers,for starters.
I sympathize with your situation,but when my generic medications
don’t work or cause side effects that the brand did not- it’s tough luck for me and countless other Medicare beneficiaries. While you may have to jump through a lot of hoops, at least you’ve been able to get the brand drugs which work for you in the end.I’m stuck taking the generic whether it kills me or not. That’s the bitter reality.
I did not find the article to be “bashing of doctors who prescribe medications that are not generic.” The article addresses a very small group of physicians who prescribe brand name disproportionately ,who are often receiving big payouts from drug companies,and who are costing
Medicare billions of dollars a year unnecessarily.

I suggest that you look into how many of those patients actually take those prescriptions that Dr.Quon is providing. My guess is that this is a front for selling those subsidized american drugs into China and making millions more. It is a well known practice to do this in China. You might want to follow up with this angle and get an even bigger story.

George Schwarz

Nov. 19, 2013, 10:27 a.m.

I agree this story puts too much emphasis on the physicians and not enough on BigPharma and Congress. The key paragraph is buried too far down in the story.

“Former CMS administrator Mark McClellan said encouraging greater use of generics makes sense. But faced with angering either the powerful pharmaceutical lobby or advocates for the poor, he said, lawmakers may see no political benefit in pushing a change.”

Yes, checks and balances are necessary for a range of reasons, including the docs who succumb to the seductions from the pharmaceutical sales people. And, the direct to consumer advertising needs to be reined in. Further, society needs to find a away objectively evaluate drug effectiveness.

Great sotry, but wrong emphasis.

Don’t forget that there’s a fairly wide network of manipulation, here, too.  When Pfizer’s patent on Lipitor ran out, they tried to make deals with big pharmacists to ignore prescriptions for generics and replace them with the brand name.  Since Part D foots the bill anyway, nobody could possibly care, right…?

So when you’re looking for sleaze, the place to start is where the biggest financial impact shows up.

Richard, just as an aside, your memory ignores history.  Twenty years ago, there was a derided package called the Health Security Act, a.k.a. “HillaryCare.”  It mandated that every American resident have health insurance and banned disenrollment until the resident had moved to a new plan.  There were also rules as to what made a valid insurance policy and encouraged “regional alliances” in some hypothetical attempt to minimize the cost to customers.

So, no.  The ACA did not come out of a secret meeting between Obama and the insurance industry.  It may have contributed to the resulting bill somewhat, but this ball started rolling two decades ago and nearly flattened the First Lady (it was supposed to be her big debut on the national stage as a serious politician) when it cratered.

Note that in both cases, by the way, insurers came out of the woodwork to talk about the horrific burden the bills would place on their industries, presumably to distract from the huge windfall they receive for doing nothing.

This is a lets trash doctors day.  Let the Obama decide which medication you get instead.  By the way folks, generic drugs use inferior products to lower costs and can be up to 20% more or less of the active ingredient (that’s the stuff we all need to get better) as per FDA rules.

Many times generic drugs are fine and should be used.

Paulette Green

Nov. 19, 2013, 2:05 p.m.

It just drives me crazy when someone starts in on the POTUS and his efforts to make healthcare available to all.  Have you ever become uninsured due to job change or are “uninsurable” due to pre-existing conditions?  I have been in both situations and it’s scary as hell and, in the supposed greatest country on earth, for this to be a reality, is just plain wrong.  We finally have begun to work on that problem, although my first choice would’ve been single payer, the ACA is better then nothing at all.  Personally, I’d prefer to have the insurance companies totally out of the picture…..for profit and health care just don’t mix.

Pauline, I totally agree with your comment on all points. I wish more people could absorb those concepts! We can hope, but with so many special interests and big bucks involved, there doesn’t seem to be any fair solution. One step forward!

There used to be a time when patients in the US used to go over the border into Mexico for cheaper drugs. Now ordinary people are going over the border for ordinary check ups, follow ups and simple procedures for “reliable and better quality of care” because they see American medicine as a mafia that controls, maneuvers and manipulates patients and the public for money, profits and medical corporate interests (which includes health insurance companies, big pharmas, etc.). 

How did we get here? And how come good doctors, hard working honest doctors, and ethical immigrant doctors are not standing against this?

Has stupidity, lack of principles and greed taken over the American medical system…like it has our judicial system?

There are excellent doctors, who are not greedy and who are very caring, ethical, competent and reliable, all at the same time. Unfortunately they are a dwindling lot.

There used to be a time when patients in the US used to go over the border into Mexico for cheaper drugs. Now ordinary people are going over the border for ordinary check ups, follow ups and simple procedures for “reliable and better quality of care” because they see American medicine as a mafia that controls, maneuvers and manipulates patients and the public for money, profits and medical corporate interests (which includes health insurance companies, big pharmas, etc.). 

How did we get here? And how come good doctors, hard working honest doctors and ethical immigrant doctors are not standing against this?

Has stupidity, lack of principles and greed taken over the American medical system…like it has our judicial system?

There are excellent doctors, who are not greedy and who are very caring, ethical, competent and reliable, all at the same time. Unfortunately they are a dwindling lot.

Christopher McCabe

Nov. 19, 2013, 4:36 p.m.

Excellent article. I would like to make 2 points though.
1) You state that “The growth has been fueled in part by the meager co-pays set by Congress.” This read to me as though you were ascribing responsbility for doctors excessive prescribing of brand name drugs to the co-pay level. Is this what you meant?
2) The observation in the comments section that for some patients the brand does work better than the generic is completely consistent with variation in individual response to therapy. It is likely that for some patients the generic works better than the brand for exactly the same reason. Whilst it is understandable for individuals to conclude that the brand name is better - it is only better for them. Concluding that this is evidence for the superiority of the brand name drug on average is invalid.You would need a head-to-head trial to establish a causal link.

Once again, excellent article.

This article is fundementally WRONG.  Medicare D is 100% formulary driven and requires prior authorization for almost all brand drugs.  Even cheap drugs like Omeprazole 40 needs prior authorization under part D.  Meanwhile, there is now a DISINSENTIVE to prescribe generic drugs because the reimbusment for them is now below the costs of dispensing them and processing the insurance.  The pharmacies are now just giving these drugs away for free….

Good job and screwing up the facts, and misreporting the real economics involved.  This is carpet bagger journalism.

Medicare D is 100% formulary driven and requires prior authorization for almost all brand drugs.

Umm…there is no one “Medicare D” formulary.  That means that what is or is not covered and the procedure required to get authorization for a specific brand name drug depends on the specific insurer.

What this article highlights is about the fact that Medicaid doesn’t have the authority to exercise the same level of brand vs. generic control that is routinely practiced by private insurers.

BTW, this is a point that doesn’t get enough attention from single-payer advocates.  The only way for single-payer to significantly lower the nation’s total expenditure on health care would be for the government to exert much more control over provider costs at all levels.  The experience with this one program, in which Congress will not even allow Medicare to negotiate drug prices should be a warning about the probability that government control of other costs would ever be accepted.

Lowell Boardman

Nov. 20, 2013, 4:47 a.m.

On one hand ProPublica attacks Generics for good reason see the Pro Publica Article on Generic Wellbutrin. On the other hand we have this pro generic article.
There is a huge problem in the economics of drug marketing. Only 2 countries the US and Australia refuse to negotiate Drug pricing with Big Pharma. Both the US and Australia allow Big Pharma to include marketing (Advertising, Sales reps, Gratuities to doctors and kickbacks to legislators via lobbyists) in the price charged to consumers, clinics, hospitals and public health providers such as the Prison Healthcare industry. The remaining countries enter into hardcore negotiations to force drug companies to compete and deliver the best medication for the least price. Why do US Taxpayers want to pay more for the same drug as Canadian, French or Swedish Taxpayers?

Paulette, insurance doesn’t make you healthy.  You “need” insurance because the medical industry is screwed up and horrifically overpriced, partly due to the issues in this article.

The ACA doesn’t make care available to anybody.  It demands that you overpay in case you ever need care.

That fear that you’ve felt?  It’s the same fear as when a thug points out that someone could wreck your business and he’ll protect you, as long as you pay a monthly “protection” fee.  The right solution isn’t to pass a law saying that we should all pay that guy.

Getting everybody medical care with minimum cost to them is a wonderful goal.  The ACA proves, though, that the President has no interest in that goal.  His saying it doesn’t make it so, just like his pledge to be transparent doesn’t make it OK to prosecute whistle blowers under the Espionage Act.

(There are very good aspects to the law, understand, like minimum coverage standards and rate transparency.  But saying that it gives anybody care when it merely demands we buy insurance isn’t one of those aspects and quite possibly the most asinine way of going about things that doesn’t blame the victim in malpractice suits.)

The metforim (sp) that I was taking was causing me to itch when I had to switch to a generic that I bought at WalMart.I found another pharmacy that made the Metforim ER in canada. The pharmacy let me have 4 pills to see if I could take it. No problem, so I have buying them when I can get them from Canada. I had a reaction to some amoxicyllin (sp) that was prescribed recently and started itching. I have taken it for years. I have been told that the fillers in some generics can cause reactions, such as metals. They have found silica in some of the generics. I have only ever found one generic that was better than the brand name and that was Deseryl (sp) and it seemed to not be as strong (the generic)which worked for me.
A nurse practitioner told me that she could not prescribe generics for MEDICAID patients, they had to be brand names. As far as I know, what does MEDICARE have to do with whether I am taking a generic or brand name. What is there involvement ? I pay a premium each month for Part D.

Armon Collman

Nov. 20, 2013, 7:09 p.m.

This is what happens when the fox is protecting the hen house!  (_:  FBI

From a retail owning pharmacist’s perspective, I hope there isn’t a big push towards generics.  Prices of generics have skyrocketed.  Insurance reimbursement has been slow to respond to these price increases.  And when they do, many times reimbursement is just enough to cover the cost of the medication.  In some cases, it’s below our cost. 

One example is albuterol tablets.  We used to be able to buy a bottle of 100 for $10.  Overnight, the price went up to $500+!!  It took several months for insurance companies to increase their reimbursement for albuterol.  And even now, while the insurance companies are paying anywhere from $100-$130 for 30 tablets, if you do the math, we would be losing anywhere from $20-$50.

Another example is Aspirin.  While this is not a Part D covered item, this is an example of the type of reimbursement we are receiving from the insurance companies as a whole.  I dispensed a prescription for Aspirin 81 mg #30.  Total reimbursement was somewhere in the neighborhood of $0.80.  Yes, a measly $0.80.  That’s barely enough to cover the cost of the medication.  Then you factor in the cost of the vial, cost of the label, cost of submission to the insurance, my overhead, my time!!!

As 1 pharmacist pointed out, pharmacies are basically giving out many generic drugs free. 

I’ve also noticed recently that a lot of the Brands that have just come off patent and a generic is now available, the insurance companies are reimbursing us below our cost. 

Of course this is all relative.  There are also generic drugs where we can make a nice profit on.  But they seem to be getting less and less as generic prices increase. 

Another thing is generics are becoming more costly.  Prices have really gone up the past 1-2 years.  Contrary to what people believe, generics are not cheap anymore. 

I understand the Brand Name Drug “waste.”  I understand the costs to our Medicare program.  But for my own selfish reasons, I’d hate to see a push for generic only.  It would be hard for a retail pharmacy to stay in business. 

I think there should be an increase in co-pay for the brand name medication.  That would drive many patients to request a generic.  At the same time, I also believe insurance companies should reimburse higher on the generics (ie the profit margin should be higher on the generics than brand).  That way there is more incentive for pharmacists to ask the doctor for a cheaper generic alternative for the patient.

My insurance( Medicare Advantage) co pay for brand drugs is so high I have to take generic even if it is less effective

If you have a loved one who is sick or has a chronic illness and needs to take medication wouldn’t you want the best drug with the least amount of side effects????  I am a tax payer who just paid a lot of taxes this year for Obama’s new health plan (I am middle class)!  If I am paying for it then I want the best for my parents and not some cheap poorly made generic medication (google it) from the 1930s that will make you even sicker. If you don’t want to take medication, then don’t take the medication and die so the rest of us can have a better quality of life.  We have already paid for it with our tax dollars, think about it people…

Sanji Fernando

Nov. 22, 2013, 7:42 p.m.

I’m concerned about the validity of the analysis - in 2011, drugs like Singulair did not have generic equivalents. And while Lipitor was offered as a generic in 2011, this was only offered as a generic in November 2011. If you are looking at 2011 annual data did you take into account when these drugs we offered as generics? This seems to undermine the convulsions of your analysis?

Another thing to consider is that many of these patients request brand name drugs because of the misconception that they are better.  This is especially true in the community this article is written about.  How do I know?  I work around there (Los Angeles, Chinatown).  As a pharmacist, I have patients complaining that such and such generic doesn’t work or is making them sick.  While I have my doubts, what am I supposed to do?  A brand name drug is not covered, I usually offer to call the doctor to see if he can switch it to a covered generic alternative.  A lot of patients get mad or tell me they want the brand and ask me to send the doctor a prior authorization form so that the doctor can apply to the patient’s insurance and request coverage for that brand name drug. 

Now if you’re a doctor and patients are telling you that the generic just doesn’t work even though in your professional opinion it does…what are you supposed to do?  Call your patient a liar?  Refuse to help your patient on the basis that he/she is complaining over nothing?  If I am the doctor, I would go ahead a switch it to a brand name drug.  It’s probably just a placebo affect but many times a patient “feels” better. 

Recently, generic Lipitor came out (as Atorvastatin).  There is a company that produces the EXACT SAME LIPITOR PILL but it’s just rebranded as Atorvastatin Everything is the same.  The pill looks exactly the same.  It’s basically Pfizer’s generic branded Lipitor.  However, when patients see the bottle and it says Atorvastatin instead of Lipitor, they refuse it, no matter how much I try to explain to them that it is the exact same product. 

What I’m trying to say is that while may doctors are not so innocent and have other reasons for prescribing Brands (such as kickbacks from drug companies, etc), they are not completely to blame.  In some cases, it may be the patients themselves to blame for this “waste”.  Just look at some of the comments above insisting that Branded drugs are the good stuff and generics are the evil stuff.  If you’re their doctor, what would you do?

DOLPH LUNDGREN

Nov. 23, 2013, 4:19 p.m.

This is just a different spin on the same old thing. The article clearly states that Medicare (after Obama reigned it in in his first term) comes in under the budget every year. Someone trying to decide who deserves name brand medication and who doesn’t? Don’t be duped.

forumsforjustice

Nov. 23, 2013, 10:49 p.m.

while at it, let’s not ignore Big PhRMA’s practice of ever-greening patents to prevent generics from being prescribed, and increasing prices, on already expensive medication.

i.e. Gleevec first licensed in 2002
In Oct. 2009 I priced Gleevec 400mg 30 tablets $3900
In Nov. 2013, Gleevec 400mg 30 tablets $6860

Dr. Hew Wah Quon is a champion.

I have met Dr. Hew Wah Quon and he is a Dr. that looks out for the needs of his patients first and foremost.

Why is he a champion?
1) He treats patients are in dire need of the best medication. Most of the people that go to see him do need the best medication because they are in very bad shape. If your grandmother or grandfather went to a Dr. wouldn’t you want the Dr. to do whatever it takes to find them the most effective drug?

2) He listens to people. Many Dr.s simply do not have time to listen to their patients because they believe that, “time is money” and they do not want to waste money listening. Dr. Hew Wah Quon will take as much time as needed to help his patients. He does a lot more than prescribe medications but actually is the one person that listens to people’s needs all day long.

3) Medicare does not make it easy for people to get the drug they need and will push them to a generic ASAP. Dr. Hew Wah Quon must have spent a lot of time filling out forms making sure people that come to him get the treatment they need. There are tons of forms and there is a lot of time involved in getting a medication authorized. When Dr.‘s do this in order to treat their patients they get nothing in return except people that are well treated and healthy.

Dr. Hew Wah Quon is a champion to his community and it is by no means right to call him out for doing everything possible to treat his patients as effectively as possible.

If the numbers are correct for the “Dr.” Quon mentioned in the article, he would have had to work 6 days per week, 12 hours per day, and filled out a prescription every 2 1/2 minutes to write 80,000 in one year. Why isn’t this man in jail?

This article is so outside the lines and despite all the information given is not all factual.  First off HIPPA is a part of the government that protects patient privacy and does not allow for information to be given regarding a patient’s health or what prescriptions are written for that patient.  Also, pharmacies in the State of California do not allow to share certain data regarding perscriptions filled for patients.  In addition, the vast majority of pharmacies throughout California are encouraged to fill prescriptions with Generics as the first choice.

Second, despite patients in certain communities, be it rich or poor are entitled to the same quality of care meaning that if a physician chooses to write brand name quality products for a patient, they can. Often times pharmacies take it upon themselves to fill a persrciption with a generic brand if the patient’s insurance dictates what they will pay for.  Besides, as mentioned above if this article was true regarding this Dr. Quon, he would have had to be writing an Rx every 2 1/2 minutes.  As an x pharmacutical representative, I find this impossible and this articile very misleading.  Don’t believe everything you read!  Physicians have absolutely nothing to gain except the health and well being of their patients through prescriptions.

Terri Bernacchi

Dec. 10, 2013, 10:24 a.m.

What is most amazing to me is that PBM formularies often cite the restriction of some products based on “safety” or efficacy reasons or step-therapy constraints.  However, as soon as these drugs move into a “generic” category, “POOF”, the “safety” concerns are gone….now they push that exact drug…as long as it is generic. 

Most formularies are JUST about cost…not safety or efficacy, unfortunately.

This article is part of an ongoing investigation:
The Prescribers

The Prescribers: Inside the Government's Drug Data

Medicare’s failure to monitor what doctors are prescribing has wasted billions of taxpayer dollars on excessive use of brand-name medication and exposed the elderly and disabled to drugs they should avoid.

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