Managed Care - March 2008 - (Page 8) LEGISLATION & REGULATION Blue Cross & Blue Shield companies are engaged in a lot of activities to get people more information on how to save money by relying more heavily on generic equivalents. Some of those programs include direct benefits to members, like waiving their copayments on generics for a period of time. Also, a variety of health plans have incentives to physicians to increase their use of generics. Under a pilot program, for example, Excellus BlueCross BlueShield in upstate New York offered four physician groups an increased rate for some types of office visits when they increased their generic “fill” rates by 5 percent. “It’s been reviewed,” says Jim Redmond, a regional vice president for Excellus, and no one saw anything that could be construed as illegal. “It’s not targeting one specific drug; it’s the overall generic fill rate.” Stojic said that the Blue Care Network program did not target a specific drug either; it looked at nonformulary drugs within a class of drugs called lipid-lowering. Excellus is acutely aware of just how much money is at stake. When the osteoporosis drug Fosamax came off patent Feb. 6, for example, the health plan noted a retail price of $90 per month. A generic alternative with the same active ingredients was likely to roll out at $60 to $70 a month, said the plan, falling to $20 per month as more manufacturers piled in. If all Fosamax users were go generic in 39 upstate New York counties, they collectively save $45. He was aiming a haymaker right at the chops of the managed care industry. “Patients should feel confident they are being prescribed the most effective medication based on their doctors’ best judgment,” said Koutoujian at the time he proposed the legislation. “It’s inappropriate for insurers to hold payments over doctors’ heads in a blatant attempt to influence prescribing decisions. Doctors should be free to make medical decisions based on what is best for their patient as opposed to what is best for some big business.” One more thing However, pharmaceutical directors have another ethical question to pose: Isn’t a greater reliance on appropriate generics good for plan members as well as insurers? “I know that managed care organizations have over the years paid bonuses to physicians or shared dollars with physicians on prescription drug benefits,” says Marissa Schlaifer, director of pharmacy affairs for the Academy of Managed Care Pharmacy. She says it is important to remember that when a patient switches to an equivalent generic, the money he saves directly is good for him. Says Schlaifer: “What’s best for the patient is to use more generics.” When it’s appropriate. “No plan wants a physician whose patient’s illness is controlled on one medication to change to a generic if it’s not the appropriate one,” she adds. Otherwise, “The most expensive medication is the wrong medication.” And as for the AMA’s objection, AHIP asked the law firm Manatt, Phelps & Phillips about it. The firm determined that the AMA’s concerns are “overblown” and that well designed generic utilization compensation programs are consistent with the AMA Code of Medical Ethics. Because therapeutically-equivalent generic drugs aren’t approved by the FDA unless they are bioequivalent and as effective as the brand-name drugs, “Physicians who appropriately prescribe generics could not be reasonably viewed as putting their interests over the interests of their patients.” MC Declined to comment The AMA declined to make any of its trustees available for an interview on the subject. Still, this issue shows no sign of going away. Peter Koutoujian, house chairman of the Massachusetts legislature’s joint committee on public health, offered a bill last December — An Act Prohibiting Drug Switching Payments — that would make it “illegal for insurance carriers’ contracts to include a specific payment to the participating provider as an inducement to change a prescription for a drug or medical product from one specific drug or medical product to another.” 8 MANAGED CARE / MARCH 2008
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