Managed Care - March 2008 - (Page 7) LEGISLATION & REGULATION Should Plans Pay Physicians To Switch Patients to Generics? The AMA calls it a kickback, but the industry sees it as just good practice to give doctors an incentive to get patients on equivalent generics By John Carroll A re doctors who take bonuses or performance incentives from health plans for boosting their patients’ use of generic drugs breaking any laws? The American Medical Association posted a document on its Web site challenging any use of financial incentives intended to persuade a doctor to change a patient’s prescription from a brand name to generic. “A physician accepting payment from an insurer in exchange for moving a patient from a brand name to a generic drug could potentially face both criminal and civil liability exposure under the federal antikickback statute,” the AMA said. The AMA also highlighted some harsh penalties: five years in prison, criminal fines of up to $25,000, civil monetary penalties up to $50,000, and exclusion from participation in federal health care programs like Medicare. There are ethical issues as well. “Under no circumstances may physicians place their own financial interests above the welfare of their patients.” For several years, health plans have saved millions by boosting the usage of generics. Prices vary, but once the active ingredient of a drug is marketed by several manufacturers, the retail price typically slides to a fraction of what it had been when the brand-name version monopolized the field. It’s not at all uncommon to offer members significantly lower copayments. However, when Blue Care Network, an HMO owned by Blue Cross Blue Shield Michigan, offered its network physicians a chance to earn $100 in 90 days for every patient who changed from a nonformulary lipid-lowering drug to a generic one, the volume of the discussion over the appropriate use of financial incentives was turned up from coast to coast, grabbing the attention of at a freelancelegislator, abeen a contributJohn Carroll, least one writer, has Massachusetts man whoof MANAGED CARE for six years. he sees ing editor has set out to prohibit what as an abuse by managed care companies. From Jan. 1 to March 31 last year, Blue Care Network asked physicians to “consider . . . if there were some patients who could appropriately be treated with generic lipid-lowering drugs,” says Helen Stojic, a spokeswoman for Blue Care Network. Doctors received lists of patients taking nonformulary brand-name lipid-lowering drugs, and the heath plan offered $100 for each patient who switched. Voluntary Stojic pointedly notes that the incentive program paid the physician to review the patient, and that the program was voluntary. “We have all sorts of people looking at our programs, including attorneys, primary care groups, and pharmacists. Everyone felt it was a program that could be beneficial.” The only refinement the state medical society asked for was to make sure that physicians were clearly told that they were to be paid to take the time to review records and counsel patients when there was an appropriate generic drug to consider. No one has accused Blue Care of legal missteps, Stojic says. In the first five months of 2007, the HMO saw its costs for lipid-lowering drugs plunge $5 million as the use of generic drugs rose. Members saved money as well, cutting their copayments, for example, from $40 for a brand-name drug to $10 for a generic. “We don’t plan to repeat the program because it took advantage of a one-time circumstance — a major lipid-lowering drug coming off patent,” says Stojic. “It was a tremendous success; we got good feedback. There’s no reason to do it again, but I think we would certainly work with the medical society if there was an interest in doing another program.” MARCH 2008 / MANAGED CARE 7
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