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Insurers entice docs to prescribe generic drugs

/ Source: The Associated Press

All the doctors had to do was show up, enjoy a free dinner at an elegant Rochester, N.Y., area restaurant specializing in steaks, chops and top-shelf wines, and pocket $100 on the way out the door.

Health insurance companies had invited the physicians to hear a pitch about the benefits of prescribing generic drugs instead of their pricier, name-brand competitors.

Meet the flip side of a concern about corporate influence in the doctor's office that's been criticized — often stridently — when the pharmaceutical industry entices doctors to prescribe brand-name drugs. Under pressure, that industry has since reined in its promotional efforts.

But insurance companies are allowed to push doctors toward cheaper prescriptions, frequently by offering the physician a form of bonus, a cut from the savings that insurance companies get when doctors prescribe generic drugs.

For example, Independent Health, a Buffalo, N.Y.-based insurer, offered doctors who prescribe 70 percent or more generic prescriptions in a month a bonus of 50 cents per patient per month. A doctor seeing 500 patients per month who meets the 70 percent minimum can collect $3,000 a year.

"On either side you've got corporate bottom-line interests putting pressure on physicians who should be putting patients first," said Dr. Jean Silver-Isenstadt, executive director of the National Physicians Alliance, an industry organization that prioritizes patient interests.

John Rodgers, executive vice president and chief marketing officer for Independent Health, said the incentive program rewards doctors for prescribing generics when possible — but it doesn't punish them if they don't.

"Our plan doesn't agree to force people off of a drug if a person makes a personal choice they can continue that drug with a higher copay," he said.

Cracking down

Some states want to more closely monitor the relationship between insurance industry representatives and doctors. In Massachusetts, a pending bill would regulate incentive plans between insurance carriers and providers. A Michigan proposal would ban financial incentives in exchange for prescribing a generic medication. That measure would allow insurance companies to compensate doctors for the time it took to evaluate whether a switch was best for the patient.

In New York, state Sen. Jeffrey Klein introduced legislation that would prevent insurance companies from offering physicians incentives. A grandfather clause would require HMOs to continue providing brand-name drugs to patients already benefiting from it. But none of these bills have gotten serious traction in state legislatures.

Last year, the American Medical Association warned that it considered the bonuses kickbacks and said doctors who accept payment from an insurer for switching a patient from a brand name to a generic drug could potentially face criminal and civil liability under federal statutes.

Caught in the middle

And caught in the middle, physicians warn that when a medical decision is taken out of a doctor's hands, it can hurt patients, such as 77-year-old Emmett Curran of Lynn, Mass.

After 10 years of taking the cholesterol medicine Lipitor, which has no low-cost generic equivalent, Curran's new insurer under Medicare refused to cover it. They insisted he take the generic equivalent of a completely different drug and he was scared.

"I'm not 25 or 30," he said. "There's something that's working for me with no side effects, why do you want me to experiment?"

His physician, Dr. Mario Motta, gave him free samples of Lipitor provided by drug salesmen. He also wrote to the insurance company to explain Curran had tried generic drugs, but in this case the brand-name drug was essential.

Still the company refused to cover it. Curran started spacing out his medication out of fear he would run out. He wound up in the hospital and had a fifth stent put in to help keep his blood vessels open. The insurance company didn't relent until Motta got the American Medical Association to make a call. Curran was covered by Anthem Blue Cross and Blue Shield, a subsidiary of WellPoint Inc. — the nation's largest insurer based on enrollment.

WellPoint couldn't comment on Curran's specific case because it would violate patient privacy laws, spokeswoman Lori McLaughlin said.

"If a member needs an exception to our formulary benefits, they or their provider have the ability to ask for an exception to our formulary benefits," she said in a written statement. "We also look at prior records we have access to and based upon those we can, in certain circumstances, approve an exception to the formulary benefits. While on average, 75 percent of those patient appeals are approved for coverage, appeals are handled in accordance with guidance from the Centers for Medicare and Medicaid Services."

Keeping costs down

Insurers say they encourage generics because it keeps consumer costs down when health care expenses are spiking. Companies argue that patients sometimes won't stick to their expensive prescription to try to save money, and a generic alternative could keep their regimen consistent.

"Health plans are not mandating to physicians what to prescribe to patients," said Robert Zirkelbach, a spokesman for America's Health Insurance Plans, a national trade association. "They are providing incentives to encourage greater use of generic drugs."

Drug companies were criticized for encouraging doctors with incentives for years. As a result, the pharmaceutical industry has imposed its own regulations in recent years, allowing only "modest" meals and inexpensive gifts with a medical purpose.

"Insurers paying physicians to switch patients from one treatment to another raises question about whether individual patient needs are being put first," said Ken Johnson, senior vice president of Pharmaceutical Research and Manufacturing of America, in a written statement.

The Rochester dinner for physicians was indefinitely delayed after The Associated Press called with questions. It was organized by a local chamber of commerce, and the stipend was paid for by various businesses, including several insurance companies. It is unclear how often these events occur, because they aren't advertised. Instead invitations are sent directly to doctors.

Most doctors enthusiastically support using generic medication — if it's an exact version of the name-brand drug.

"There are drug classes that you can switch from one drug to another, and there are some that you can't — and the person deciding that should have a medical degree," said Dr. Marc Siegel, an associate professor of medicine at New York University Medicine.