A policy change by health insurer Capital District Physicians Health Plan to make a switch from prescribing brand name drugs, such as Lipitor and Crestor, to generic drugs in order to cut down health-care costs has some physicians celebrating and others ready to fight back.
In a memo to practitioners, CDPHP stated that during a June 16 meeting with the Pharmacy and Therapeutics Committee, made up of 17 voting member-physicians and two voting member-physicians who practice in the community, the health insurer will no longer be covering brand-name drugs and begin issuing generic drugs when prescribing medication for high cholesterol.
The changes will go into effect on Oct. 10.
We’re constantly looking for ways to balance the costs for our patients, said CDPHP Public Relations Manager Kristin Marshall. `The perception out there is brought on by the marketing of brand-name drugs, but no one is marketing generic drugs.`
The decision was made in order to cut down on rising health-care costs, said Marshall, who added that there are drugs out there that can perform in the same way as the brand-name drugs at a lower cost.
`There might be a slight molecular difference, but we wouldn’t be making this decision if we thought it was wrong,` she said.
With Crestor, a 40 mg dose will reduce a patient’s cholesterol by 50 to 55 percent, according to Dr. Russell Zivkovich, who owns a family practice in Cohoes, while a patient using an 80 mg simvastatin, or the most effective generic brand, must take an 80 mg dosage to reduce their cholesterol by 47 percent.
The U.S. Food and Drug Administration released a study in March 2010 finding `an increased risk of muscle injury in patients taking the highest approved dose of the cholesterol-lowering medication, Zocor (simvastatin) 80 mg, compared to patients taking lower doses of simvastatin and possibly other drugs in the ‘statin’ class.`
`A higher dose of simvastatin puts the patient at greater risk of injury or death,` said Zivkovich. `CDPHP doesn’t have a license to practice medicine, but they are telling me how to practice.`
Zivkovich said that most doctors are irate over the change in policy but are too afraid to speak up for fear of being dropped by CDPHP.
`Seventy percent of my time is spent writing a note to document something for insurance companies to make them happy,` he said. `[Before health insurance companies], there was better medicine, better care, and I wouldn’t have to be buried in paper work.`
Patient care is Zivkovich’s main concern, which he said the new policy change by CDPHP is restricting him from doing right by his patients. He accuses the health insurer of `putting money in front of patient care.`
He also said switching to generics could actually be more expensive after rebates given by doctors for brand-name drugs. For example, if a patient needs to pay a $25 co-pay he can give them a coupon for a $25 rebate on the drug, essentially reducing the cost to nothing for the patient.
`It’s cheaper to get the better drugs,` Zivkovich said.
Another argument that has been made by some physicians is that patients who have reached their cholesterol goal on small doses of Lipitor will not be able to tolerate changing to a generic.
Cohoes Mayor John McDonald, who works for Marra’s Pharmacy, said that in those cases, CDPHP will provide a way for the patient to access a brand-name drug such as Lipitor or Crestor.
`There will be people who have treatment failure,` he said. `CDPHP will provide access to the brand-name drug, but it has to be clinically justified.`
Dr. Laura Staff, who runs her own family practice in Colonie, said the application to get those drugs have become increasingly easy over the years, as now a doctor needs to fill out one form on one side of the page showing the patient has failed three months on 80 mg dose of simvastatin and three months on an 80 mg dose of pravastatin. She also added that it only takes a short amount of time to fill out the application.
`If [the patient] does as well on the generic as they do on the brand-name, then they don’t need to go back on the expensive drug,` she said.
Zivkovich has a different take on the process as he said waiting for a patient to fail on the two statins and Lipitor, which is on a preferred basis, could take up to nine months. It is a wait, he said, that could cost the patient his or her life.
`What if [the patient] dies during those nine months,` he said. `The insurance company wouldn’t back me up on that. Whether the insurance company covers [Crestor] or not, I can’t use the excuse that the insurance company wouldn’t cover it in the court of law.`
While Zivkovich says the new policy is designed to bury doctors in paperwork in order to force them to take the easy route and just prescribe the generic drugs, he said refuses to follow those guidelines and will continue to prescribe the brand-name drugs.
`When I do prescribe generics, I tell my patients to go to Wal-Mart because they have a cash plan,` he said. `Because they pay with cash, it doesn’t get submitted to the insurance company, so it costs less.`
Another component of the change in CDPHP’s policy is that they are offering doctors $50 per phone call in explaining the new policy changes. Staff said the money is meant to cover the costs of pulling a patient’s chart, reviewing it to see if a generic brand would be adequate and making up for the time it took for the physician to make the call.
`In a 15-minute dialogue you could explain the rationale, where to go from here and what monitoring needs to be done,` she said. `It’s making honest doctors who would have to absorb the cost of that not have to make the patient come in.`
Zivkovich sees the money as a bribe.
`This needs someone with a lot of money to hire a lawyer to challenge these policies,` he said. `I hate insurance companies. I wish they’d all go away.`
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