Physicians’ and Patients’ Views of Generic Drugs

1. Physicians’ and Patients’ Views of Generic Drugs John E. Billi, MD University of Michigan Health System

2. Generics: Issues • Patients concerns about generics - quotes • Role of 2 or 3 tier plans • is a copay a disincentive or cost sharing? • DAW: a morass • Fought for it, yet poor value • DAW insensitive • The win-win rationale: • everyone benefits from better prescribing • takes time to deliver the message to patients • Pharmaceutical Benefits Managers - caution

3. UM Physicians report what their patients say about DAW • What I hear from my patients: • “generics don’t work for me” • “I don’t trust generics” • “I read that generics are not the real thing, they are not pure” • “why change something that is working?” • The most common thing I hear is: "The generic form doesn't seem to work as well." Of course, after some probing this is usually entirely subjective, and gives me a chance to explain the differences between the two forms. Most patients are open to receiving generic forms once I have a chance to dialogue with them.

4. Physicians report what patients say about DAW • I get this all of the time, predominantly for narcotic-based prescriptions. Although they don’t admit this, the DAW version does have a significantly higher street value. Practicing in (X), I’ve come to know this.... • Just the other day, a patient told me she had read an article about a generic manufacturer whose pills were not dissolving in the gut. She was certain quality control lapses or engineering flaws were more likely to be found in generic drugs and would now refuse all non-brand medications. • I have found that the most common reason is a perceived lack of efficacy of a generic medicine in the past.

5. Physicians report what patients say about DAW • In addition to ‘intolerance’ or ‘allergy’ arguments which are frequent, I hear from patients on certain chronic medications that they fear that generics are less reliable. Thyroid replacement and warfarin are two very common examples: patients report having more difficulty stabilizing TSH and INR with generic preparations than with synthroid or coumadin. I’ve also heard many of my colleagues express the same belief.{NOTE: MOST GENERIC SUBSTITUTION PROGRAMS ALLOW COUMADIN, BUT NOT SYNTHROID – JB} Others seem to feel entitled to brand names, and feel as if they’re being slighted if given a ‘cheaper’ generic. I find this commonly among patients who feel a reason to mistrust. I will say that recent “tiered” copay structures seem to have dampened this. I now have many patients *requesting* generic medications to keep their out of pocket expenses down. • For children, the brand name taste better.

6. Physicians report what patients say about DAW These comments are just from one afternoon of seeing patients at Briarwood Family Practice. • “Generics are just not as good.” • “Generics never work for me.” • “Please check DAW and write out dispense as written since I have the best insurance so I can have the best medication possible.” On the opposite end: • “Is there a generic for Premarin, the price has gone up so much I can’t afford it anymore.” • “Can we use generic since it will not be as expensive.” • “Can we change to another drug that does come as a generic?”

7. Physicians report what patients say about DAW • I recently had a patient in my internal medicine clinic say that he takes generics whenever possible, even if brand name alternatives are available. He says that he wants to save the health care system the extra money. • In response to your request for DAW anecdotes - - I have taken care of at least two patients who have also stated "I am allergic to generics". I noticed that recently one of the large insurance companies has started an ad campaign with the slogan "Generics - the other brand name". Perhaps this will help all of us !

8. Physicians report what patients say about DAW • Conclusions: • Many patients distrust generics’ quality • Many patients feel they earned brand coverage and so should use it (if not used, it is lost) • Patients have been misled to believe brands are of great value, yet it wastes money better used elsewhere • Physicians favor cost sharing (tiered copays) to engage patients’ financial interests

9. Differential Copays and DAW • Tiered copays have 2 goals: • cost sharing (like a % copay) • higher cost = higher copay • incentive to use lower cost drugs - a “penalty • DAW insensitive, tiered copay: • allows the physician to write “DAW” • pay the brand copay regardless of “DAW” status • rationale: it is not a penalty, it shares cost - the brand drug does cost more • benefit to all in lower future copay increases

10. Dueling FormulariesHow many were going to St Ives? • Each patient has a payer • Each payer has its PBM • Each PBM has its PDL • A doctor has to know each patient’s payer’s PBM’s PDL to prescribe “appropriately” • Or else: -blocked at pharmacy • calls, letters, faxes from PBM or pharmacy for preauthorization or “switches” • higher copays for patients • Poor “profile” • RX HUB and palm formularies

11. The All-Patient Solution • Simple message for ALL patients and ALL physicians, regardless of coverage type: Use the lowest cost, appropriate drug • if uninsured, lowest cost drug is least $ for the patient • if double or triple tier, has lowest copay and keeps open formulary; keeps copays lowest for each tier • if single tier, will increase likelihood it will continue, and limit future cost sharing This is the best way to preserve coverage for those who have it, and lower cost for those without.

12. Pharmaceutical Benefit Manager - Friend or Foe? • Contracted by employers and health plans to maximize value of drug expenditures • Receive majority of funding through pharmaceutical industry: rebates, market share, “educational programs”, “formulary loading” • Some are under federal investigation

13. PBMs: Serving Whose Interests? • One PBM’s performance drug list is 70% brand name drugs • Their education promotes brand drugs: • COX 2, non-sedating antihistamines, SSRI, PPI • If you eliminate their SSRI from your Preferred Drug List, then they eliminate the rebate for your most common statin (bundling) • PDL determines tier 2 of a three tier benefit • Letters to physicians with lists of patients: • on NSAIDs - “consider COX 2” • on PPIs - “switch to Nexium”

14. Improve Pharmacy Appropriateness Complex problems sometimes require multiple approaches • UMHS Preferred Drug List • Developed by Ambulatory Formulary Comm. (physician, hospital, MCare) • Based on drug class analyses by UM pharmacists • Optimize costs, multiple HMOs’ Preferred Drug Lists (MCare, BCBSM) • Available on web, CareWeb reference, palm, updated frequently • Laminated cards (drug by payer) sent to all faculty/HOs, posters for clinics • Academic detailing programs • Pharm D from UM: offer physicians to switch specific patients • BCBSM savings-sharing pilot, Pharm D from BCBSM • COX2, PPIs, statins, SSRIs, sinusitis drugs, generics, dose optimization • Pharmacy Benefit Manager actions • PBM hard edits for dose optimization & COX 2 • BCBSM voluntary program encouraging generics and dose optimization • House staff intervention: plan from HO rep., peer-to-peer, lunch • Developing policy limiting pharm rep interactions further

15. Improve Pharmacy Appropriateness Continued • UM Campus changes: all employees, retirees, dependents, 1/1/03 • Carve out pharmacy for all groups (HMO, BCBS, etc) • Triple tier • Campus Pharmacy Oversight Committee; Advisory Committee • Ban samples in UM sites • New Sample Drug Policy adopted by ECCA 7/02 • Safety and JCAHO risk (inventory, lot #, expiration, instructions, recalls) • Studies show samples influence prescribing • Prohibited from long term use • Indigent care pharmacy programs - coordination: UM Pharmacy, Amb Care • Vouchers for preferred drugs: MCARE and BCBSM may fund generics • Ambulatory Formulary Committee coordinates actions: • UM Pharmacy, GUIDES (Guidelines, detailing & measurement), Inpatient P&T, MCare P&T, FGP Managed Care Committee, Medical Management Center, Campus carve-out

16. Next Steps • Communication plan • Better specialist involvement: • in Preferred Drug decisions • identify a faculty contact for each specialty for peer education • Managing PBM conflict of interest • Maximizing rebates is not the goal! • ibuprofen to COX 2??? Prilosec to Nexium??? • New Policy: pharmaceutical sales representatives