Journalism in the Public Interest

Generic or Name-Brand? 10 Docs Talk About Picking Drugs

With billions in potential savings for Medicare at stake, we asked drug experts and practitioners alike why more doctors don’t recommend generics when they can. 

With billions in potential savings for Medicare at stake, we asked drug experts and practitioners why more doctors don’t recommend generics when they can. (Nathan Weber for ProPublica)

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.”

Good story.
I would also like to know:
How do individual physicians’ drug prescribing patterns dovetail with ownership of interests in pharmaceutical corporations?

Many generic drugs are different from the brand-name because of dosage, and timed released substances that are not part of the “generic” reproduction.  This has caused a lot of problems for people taking generic drugs thinking they are the same as the brand-name.  There needs to be more awareness of this in balanced reporting.

Claire Gaines

Nov. 20, 2013, 4:16 p.m.

I have taken a particular brand-name medication for over 30 years—well before a generic existed.  It has been effective and I have had no problems.  My doctor and I do not want to risk any possible problems due to use of a generic which may indeed be different.  If I am willing to pay the cost of the brand-name, whose business is it anyway?

As a pharmacist (PharmD), my colleagues and I repeatedly contact prescribers to change to equally effective medications that are available as generics. I’m not talking about generic substitution, I am talking about an equally effective medication in the same class. 

Usually, I find there was not a clinical reason for picking a certain brand-name-only medication when another effective generic medication in the same class is available. Almost always, the prescriber accepts my recommendation, the patient’s condition is treated, and the patient and health care system save money.

Byard Pidgeon

Nov. 20, 2013, 4:43 p.m.

I have close relatives who work in advertising, so I want doctors to prescribe only brand name drugs in order to keep my family members employed.
Besides, my congressional representative gets a lot of money from drug companies, and since I can’t afford to support him as well as they can, I want all doctors in my district to prescribe only brand name drugs.
Given a bit more time, I’m sure I can come up with a long list of equally compelling reasons to always prescribe brand name drugs.

Most of these doctors that prescribe name brand drugs are very well cared of by their pharmaceutical sales rep. They receive a lot of perks when they prescribe name-brand drugs. Unfortunately, they care more about themselves than their patients.

Arthur Naebig

Nov. 20, 2013, 8:55 p.m.

My doctor would give me a few samples of a medication and tell me to call him for a prescription if I was happy with the results. Of course, the samples would be from the company with the latest and most expensive version. I came within $300 of the ‘donut hole’ one year. Then I learned more about generics from Consumer Reports and brought in Walmart’s list of $4 prescriptions. He found older generic medications to prescribe that do the same job for $4 a month.

If you are paying your own money for your drugs, this article doesn’t pertain to you.
If the government is helping pay for your drugs, the money is from taxes on the rest of us (what isn’t being borrowed).  If there is no valid reason
for using a brand drug when there is a genetic available, then that is
government waste which everyone deplores.

I take generic whenever possible for the simple reasons that:

a They are less expensive.

b They have been proven to provide effective active ingredient equivalency for a proven period of time without compromise.

c The latest and ‘best’ are sometimes found to have sever problems that do not show up until taken by a large enough number of patients needed to establish a safety element and overcome the hype of marketing ASAP.

One factor that should be considered: many generics do NOT mirror their branded counterparts in terms of quality and potency.

Many honest medical professionals (yes, there are some) will also tell you this.

The active components of generics is the same, but the fillers/stabilizers can be different. And different from one generic manufacturer to the next.  When your pharmacy buys lowest cost they are often switching you from one generic to another, and this can cause problems.  Allergies to the fillers/stabilizers can have very bad outcomes.  Wish we’d stop making medical decisions primarily based on cost, and instead on quality.

After reading about the Ranbaxy debacle (Indian pharmaceutical company), with test results being faked for their generic drugs, I am not interested in the supposed cost savings of generics. 

I would rather pay a bit more for the real thing until the FDA cracks down on this nonsense like they should be.

It’s worth pointing out, I think, that this discussion is worthless if it’s just about brand-name versus generic.  As some point out in a pointlessly huffy manner, there are some brand-name drugs that are worth the obscene prices if they help.

The discussion should be about doctors selecting brand names when viable alternatives exist.  As I mention elsewhere, Pfizer tried to get the national chain pharmacies to prescribe Lipitor over generics when their patent expired.  They didn’t do this because the generics weren’t as effective or were buffered with plutonium or anything; they did it to maintain a monopoly.

Saying “but some generics are garbage” ignores that some companies are run by garbage, and vice versa.  The result should be to get the best results, no?

I have to completely support the reasoning Dr. Reznik gave which has to do with ease of recognition by some of the elderly. For the rest of us, go generic whenever possible.

I am a member of Kaiser Permanente in California.  When I was prescribed Spiriva for COPD I found that the Kaiser paid portion of my prescription was ABOUT $700.00 while my out of pocket co-pay was $90.00 for a 90 day supply which, over the course of a year, would put me in the donut hole.  My doctor had no idea of the cost until I informed her.  I was told that Spiriva was prescribed as there was no generic.  Amazing!!  I n ow have her give me a hard copy of my prescription whjich I have filled through a CANADIAN pharmacy at a cost of $80.00 which includes postage.  The CANADIAN pharmacy sends me tiotropium bromide which the Spiriva package also it is.  One of these must be a generic.  In fairness to my doctor she does not ever meet with the pharma sales reps and has no idea the costs of the meds she prescribes.

As a physician, I try hard to prescribe reasonably priced drugs for my patients. However, it can be difficult; respiratory drugs, in particular, are available only in name brands (thanks to slick maneuvering by Pharma, re-issuing their drugs in CFC free forms as they were about to lose their patent protection). I sometimes spend half of patient visits trying to be sure patients can afford what I am about to write them.

When I was on a residency faculty, I had to actively prevent resident physicians from prescribing off the sample shelves. Now, in the private world, I base prescribing decisions on what fits a patient best in terms of their various disease processes, lifestyle, and what they (and their insurance) can afford. Interestingly, those without insurance sometimes get branded drugs because I know the patient assistance programs to get these for them free…

Marty Kassowitz

Nov. 26, 2013, 4:22 p.m.

Doctors I see try to recommend generics as much as possible. One told my point blank that there’s nothing at all wrong with drugs from Mexico or Canada. I buy all my asthma medications overseas as the US drug companies and drug chains are engaged in rampant price gouging. For example, AdVair by GSK costs about $200 for a 30 day supply in the US. Buying it in Mexico (under the name Seretide) it costs $47. The Mexican product is exactly the same as the US version but has a different brand name and is also made by GSK. Here’s another example. The generic version of the antibiotic Levaqin costs $21 at a small independent pharmacy, for a 7 days supply. At CVS, the “discounted” price is about $125. Same deal for WalGreens and RiteAide. WalMart was cheapest at $84. This has price-fixing written all over it. Which amounts to massive consumer fraud.

Whoa, not so fast, Pro Publica.  You are passing over millions of “experts” who have experienced the difference between generic and brand name.  I, for one, can tell you the generics can be dangerous.  The idea that cheap, cheap, cheap as the only criteria because generics are exactly the same as brand name is fallacious.  Generics are now big business and have a powerful lobby that can sway the Food and Drug Administration into making some bad mistakes for the American public. The lobby group for the generics industry has gotten the FDA to let them VARY from the original drug formulas in ways that are not in our best interests.  Pro Publica, you need to dig further into this story.  CHEAP but equal is not what is seems.  Bio equivalency is not a straight across the board equivalency.  Bio equivalence is an involved test that generics tend to avoid.  And ingredients from India and China?  Many source countries for generic ingredients do not have the same standards for individual human lives as the United States does or used to.  Look deeper - don’t take a trade groups word for it.

Gretchen Kromer

Dec. 3, 2013, 2:27 p.m.

Tod Cooperman, President of ConsumerLab, cautions against assuming that generics are always a cheaper equivalent of brand name drugs, In the case of drugs where exact dosage is critical, such as thyroid medication, blood thinners, and anti-depressants, doctors and patients should proceed with caution.

In my own case, after taking years to get a thyroid condition stabilized and having experienced that generics did not work the same for me as Synthroid, I am not willing to do any further experimenting. I would not like to see my doctor penalized for going along with my wishes in this matter.

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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