Guest Blog: Real Influence, Pharma or Insurers?

With the recent proposal to repeal the so-called Massachusetts “gift ban” (referred to from this point as the “interaction ban”), I asked myself who stands to gain the most from such bans? Is it the consumers or patients?  Is it the physicians or their practices? Is it the federal or state governments?  Nope. Sadly, it is the insurers who gain the most, at the expense of patients. 

The argument for interaction bans is that generics will save money over name-brand medicines, which are being “unnecessarily” or “irrationally” prescribed (as defined by whom?). What is forgotten is who wields the most influence over the decision to prescribe a medication. The public is convinced that it is the physician, and, actually, that would make sense.   More recently savvy public relations campaigns and advocacy efforts have convinced legislators (and the public, so the advocates claim) that it is the Pharma rep that controls prescribing. In reality, it is the insurance companies.

Insurance company actuaries decide which drugs are on the formulary (what they will cover) and which one is a preferred name-brand medicine (cheaper co-pay), based on benefit-to-the-bottom-line calculations.  Ironically, some generics are not even on a formulary list and are NOT preferred over name brands. Consequently, these decisions, which are based on the whim of the insurer, dictate whether a patient has access to a medicine, not their physician, and definitely not the Pharma rep.

Does an intelligent Congressman or Senator really believe that a patient will blindly order a name brand drug when generics are available?  What would they do in that situation?  Why would they think the general public will be so eager to simply accept a costly name-brand medicine when money could be saved? Are Congress members so far removed from reality?  Some of my patients have to decide to forgo either food or medications.  I hope Congress members realize they lacked the proper infomation about the situation and correct their version of reality!

For example, it is already extremely challenging to get a name-brand medicine when it is medically necessary.  Many states have laws that mandate generic interchange (substitution when the active ingredient is the same); physicians must fill out prior authorizations, which are labor-intensive and represent uncompensated work; and pharmacies are pushing cheaper alternatives due to higher profit margins for them.

Among all these competing forces, where is the logic, or evidence, that a patient can walk into a physician’s office and end up with an unnecessary and expensive bottle of pills solely because of a Pharma rep?  Only in the minds of idealistic social science researchers who claim that a pen with a name brand label will overcome all these obstacles. Sadly, the true issue at hand is that many physicians will or cannot perform the extra work to obtain a name brand drug when it is safer or works better than a generic because of the extra time or staff involved with the myriad paper-work, which is a real cost-driver of health care.

So the next time you hear of the egregious cases of Pharma exerting their control by ‘wining and dining’ physicians, take a moment to consider who really stands to gain by the proposed solutions and whether patients have even entered into the equation.

Edison Wong, MD

Physiatrist, Massachusetts