
An effective eye drug is $50, but many doctors choose a $2,000 alternative - jorganisak
http://www.washingtonpost.com/business/economy/an-effective-eye-drug-is-available-for-50-but-many-doctors-choose-a-2000-alternative/2013/12/07/1a96628e-55e7-11e3-8304-caf30787c0a9_story.html
======
DannoHung
Top comment from the reddit thread on the same article:

"Ophthalmologist here.

As a physician responsible for prescribing and injecting these drugs, I can
tell you that this article glosses over the single most important factor
involved in deciding between the three currently-available Anti-VEGF options:
compounding pharmacies, and the lack of regulation thereof. Any
Ophthalmologist at this point is very familiar with the results of the CATT
study which confirmed the equal efficacy and safety of bevacizumab (Avastin)
and ranibizumab (Lucentis). The reality is that the actual drug injected into
the patient's eye either comes from the manufacturer in a sterile, ready-to-
inject form (Lucentis), or an appropriate amount was prepared for intraocular
injection by a local compounding pharmacy (Avastin).

Compounding pharmacy regulation is notoriously poor, and the risk of an
intraocular infection is not one many retina specialists are eager to take
unnecessarily. Endophthalmitis frequently leads to blindness, even with early
diagnosis and treatment. As much as everyone wants to think doctors are only
interested in lining their pockets, the reality is that most of us simply
don't want your grandparent going blind in one eye because a minimum-wage tech
at a compounding pharmacy failed to follow appropriate sterile procedure. The
American Society of Retina Specialists have been advocating for increased
regulation of compounding pharmacies since Lucentis became available. Check
out their website.

I guess I should also point out that we get paid the same for injecting any
medicine into the eye, regardless of the cost of the drug. And we purchase and
stock both drugs in the clinic, and bill insurance for whichever is used. So
we don't benefit financially for injecting one versus the other."

[http://www.reddit.com/r/politics/comments/1sdxz6/an_effectiv...](http://www.reddit.com/r/politics/comments/1sdxz6/an_effective_eye_drug_is_available_for_50_but/cdwoh5j)

~~~
manicdee
Is the implication here that the technician at the "manufacturer" is not
minimum-wage?

Or is the implication supposed to be that the minimum-wage technicians who
work for the "manufacturer" are magically better at following appropriate
sterile procedures?

~~~
refurb
I think it's a fair comparison for the following reasons:

1) Manufacturer techs get paid a hell of a lot better than compounding
pharmacy techs. I knew guys in the pharma industry, nothing more than high
school pulling down $100K/yr with overtime.

2) There has been a recent incident
([http://en.wikipedia.org/wiki/New_England_Compounding_Center_...](http://en.wikipedia.org/wiki/New_England_Compounding_Center_meningitis_outbreak))
where 48 people died and over 700 got sick from poor compounding pharmacy
controls.

------
naner
Here's a reply purportedly from an O.D.[1]:

 _Eye doctor here. Avastin is currently used off-lable for eye conditions
(most commonly wet AMD and macular edema in diabetes). It is only FDA approved
for use in treatment of some colon and lung cancers. Generally speaking, even
though it fits standard of care within the field of ophthalmology to use this
drug, there are still some inherent risks in doing so for the practitioner,
thusly, Lucentis is still preferred by some. Also, I 've not encountered this
(as MOST insurance companies would prefer practitioners to use the cheaper
drug) but I've heard of difficulty with third party payer coverage/
reimbursement when using the off-lable drug.

Another thing to consider, as ajrw pointed out, they ARE NOT as the article
mentions "the same drug." Some people respond more favorably to one versus the
other. Commonly, the two will be used in succession on the same patient as
though no double blind clinical trial has been done to confirm this; both
drugs tend to exhibit a slight tachyphylaxis over time (diminished effect).
Practitioners have found that when one drug starts becoming less effective,
switching to the other VEGF inhibitor can show recapture of the previous level
of therapeutic benefit.

I would advise all to take this article with a huge grain of salt. Most
practitioners are not aiming to increase insurance costs (obviously, as
generally speaking, the higher the bill, the harder it is to get the
reimbursement.) Many are probably apprehensive to use an off-lable drug from a
medical-legal stand point.

Note: I am not a surgeon. So some of this is slightly presumptive._

1:
[http://www.reddit.com/r/politics/comments/1sdxz6/an_effectiv...](http://www.reddit.com/r/politics/comments/1sdxz6/an_effective_eye_drug_is_available_for_50_but/cdwmfro)

------
pinaceae
Complicated topic on a global scale.

The rest of the world is very grateful for the US pharmaceutical market. Its
unregulated and "free" nature, like consumer advertising for prescription
drugs - something completely unheard of in civilized countries - allows for
massive profits for the pharmaceutical industry.

those profits do not happen anywhere else. european agencies control and
negotiate prices centrally, emerging markets seems to follow the european
model (brazil, china, etc.).

those profits do get invested back into r&d, the patent system forces pharma
companies to move forward. the recent patent cliff is a great indicator for
the system working.

pharma r&d would be severly constrainted if not for the profits generated in
the US market. on a global scale it looks like a subsidiy by the US people,
paying high markups and taking way more drugs than needed - for the good of
the rest of the planet.

thank you. and keep swallowing pills.

------
dekhn
The article left out a number of very good scientific reasons why lucentis and
avastin are _not_ bioequivalent and should not be subsituted.

I found it especially misleading that they used anecdotal evidence to claim
that the cheaper drug is equivalent in function and safety.

That said, Genentech is on the wrong side of the PR angle here and
unfortunately for them, some internal documents got exposed which make them
seem less than angelic here. If the cost differential of producing the drugs
really is small, then they don't have a strong position, because it makes them
appear as if they are using one of the drugs as a profit center to fund future
R&D.

Anyway, the article really glosses over stuff, but you'd need to spend about
5-7 years getting a PhD in pharmaceutical chemistry, plus working in industry
for a few years before you understand the business and science of what
genentech does.

~~~
ams6110
_they are using one of the drugs as a profit center to fund future R &D_

How else are they going to fund future R&D?

~~~
dekhn
to clarify:

they are using one of the drugs moreso than another as a profit center.

IE, given no other constraints, I'd expect a pharma to distribute its R&D cost
over its drug profit centers weighted by the drug's profit margin, and that
all the drug's profit margins would be roughly equal: naively, I'd expect them
to raise the price of Avastin and lower the price of Lucentis, assuming the
costs of producing them truly are similar.

The reality is, likely there are proprietary reasons we're not privy to that
causes the cost differential. They could be technical (maybe it does cause
much, much more to produce Lucentis), or the could be business (maybe
increasing the price of Avastin could cause it to sell poorly against another
drug from a competitor)

------
naner
Doctors will typically prescribe the "best" drug to their knowledge which
often means the newest drug with the least serious side effects. I don't think
they are always out to bilk their patients.

If you are ever in a situation where you have to pay for drugs out of pocket
or your insurance doesn't cover enough of the drug _call your doctor and ask
for a lower cost alternative_. They can call the pharmacy and often times find
a lower cost alternative to fit your budget.

At least this has been my experience with my doctors. I have also had my
primary physician straight up tell me the price difference between the best
choice and second-best choice doesn't justify the benefits.

~~~
FireBeyond
/I don't think they are always out to bilk their patients./

"Genentech also provides rebates to doctors who prescribe large amounts of the
drug."

"Rebate"? No, it's a kickback. Unless somehow the doctor is paying for the
patient's prescription.

~~~
eyeguy
In this case, that is not true at all. I worked for a large retina group for 6
years and now consult for several different retina and general ophthalmology
practices, so I'm a little biased, but I've also been lucky enough to see
these new drugs through various stages. First of all, Doctors are the ones
buying the drug, and they have to keep enough inventory on hand to treat the
patients that need it until the next delivery day. The introduction of these
higher priced biologics has had a huge affect on the way practices (especially
smaller ones) have to manage their inventory. The last practice I worked for
was buying between $1.2 and $1.8 millon worth of lucentis, a few hundred grand
worth of Eyelea and a boatload Avastin every month. If anything goes wrong
during the reimbursement process and the practice isn't paid as expected, it
can be devastating. When the use of these drugs started ramping up, there were
definitely a few scary payroll periods for us. Putting the right inventory
management procedures in place significantly helps this problem, but there's
definitely some stress knowing you're on the hook for over 2mil each month.
Genentech's rebate and Regeneron's extended payment terms are efforts to
alleviate some of this stress on providers while ensuring they are keeping
enough stock on hand that they aren't having to bring patients back for a
follow up visits just to order the drug. (some practices will see a patient,
diagnosis, reschedule for follow up injection, then order the drug. This just
wastes everyone's time) Even more importantly though, as said elsewhere in the
comments, these drugs are definitely not the same. A lot of us, even the docs,
in the industry joked about the high price of Lucentis when it first came out
and many doctors (though I'm not sure on the exact number, but I think I
remember hearing 80% of anti-vegF injections were Avastin not lucentis) used
avastin over lucentis specifically because of the price. In the past few years
however, this thinking has changed and it has very little to do with the
reimbursement model. In the beginning, these drugs were simply awe inspiring.
Before the availability of these drugs, a retina doc's approach to AMD was,
"here's an amsler grid.. let me know if anything changes (it will), we'll see
you in 6 months to asses how much more blind you've become. There are some
vitamins you can take that might slow things down (barely), and oh yeah, there
is this cold laser treatment we can try(PDT)that will just shut down that area
and maybe prevent the spread. That treatment is going to require us to infuse
you with a drug for 15 min, then shoot a laser in your eye for 83 seconds.. oh
then after that, we are going to wrap you like a mummy because any form of UV
is going to burn the shit out of you.. fun stuf" Now all of a sudden here is a
drug (Avastin) that takes half a second to inject, and not only preserves the
vision that you have, but if we catch the leakage early, it can even dry it up
and improve your vision! I was fortunate enough to work on some of the early
trials and honestly the follow up visits were just breathtaking. NVAMD used to
be a death sentence to vision.. now it's merely an inconvenience that can be
overcome. With that success came Lucentis (Avastin was being used totally off
label) an FDA approved drug that was crazy expensive. Patient's couldn't
afford it, no one really used it. Then medicare and some other insurances
started having issues with off-label use and it actually became easier to get
reimbursed for using Lucentis. The CATT trial started and some issues started
being raised over whether or not Avastin was actually safe long term. Then
there was the scare in Florida were a batch of Avastin from a compound
pharmacy was contaminated and a ton of patients lost their sight to
infections. So we started using Lucentis a little more frequently, just to
see. While the Catt trial shows the two drugs are pretty equivalent.. in
everyday practice, it's becoming more apparent that this is not the case. Some
forms of AMD respond better to lucentis than Avastin. Diabetics with Macular
Edema sometimes respond quicker to Lucentis (and even faster with Eylea!) It
becomes more about finding the right drug for the individual patient than just
choosing the cheapest option. Most doctors are not trying to screw their
patients over, and have protocols in place for finding the best possible drug,
and, in my experience at least, most of these protocols do consider the
affordability to the patient as well as the effectiveness. (Personally, I
think there are genetic variants of these diseases that determine the
effectiveness of the drug, we just don't fully understand yet.. once we can
more accurately test these variants and build trials around them, this will
become more of a non-issue) A few years ago, I would have totally agreed with
this article, not anymore. The sad truth is profit drives innovation, it's a
bitch developing new drugs, and their has to be enough of an incentive both
financially and medically to encourage progress in that field. At the end of
the day, the majority of the doctors out there just want was is going to be
best for their patients and are continually re-evaluating their strategies to
ensure that goal is met.

------
judk
> In addition, Genentech offers rebates to doctors who use large volumes of
> the more expensive drug.

But doctors don't buy the drug, patients and Medicare do. So it is straight up
bribery of people abusing legally protected positions of trust?

~~~
jrockway
Or, they don't want to explain in court why they picked the cheap drug and the
procedure went wrong.

~~~
kvb
Particularly when the cheap drug isn't FDA approved for the treatment in
question.

------
patatino
I live in a small village and whe have two doctors. After visiting doctor A
you'll leave with a bag of drugs, doctor B will not give you anything more
than you need, even if you ask for it. The crazy part is people prefer doctor
A..

~~~
yaddayadda
When I was growing up my father told me a parable of three brothers, all of
whom had grown to be doctors.

One brother was a miraculous curer of all injuries and ills. It did not matter
how far a disease or injury had progressed, he could cure the patient. He was
known throughout the continent.

One brother was exemplar diagnostician of all injuries and ills. It did not
matter what was wrong, he could diagnose the problem and if he was unable to
solve the problem he would make a personal introduction the most knowledgeable
expert on the matter. He was known throughout the country.

The third brother was just a humble backcountry physician. He wasn't very good
at diagnosing or curing diseases. But he visited his clients frequently, and
gave them advice on their diet, and home and work conditions. On the rare
occasion when his clients got ill or injured, he tended them back to health
and when possible helped them to remove the conditions leading to the ill or
injury. He was only known throughout the village.

~~~
alphaoverlord
And finally there is Dr. Oz, who talked well, was attractive, knew Oprah and
was interested in talking about all sorts of diseases and conditions outside
his training. He has a TV show, multiple book deals, is a millionaire, and
doesn't have to see a patient.

------
mistercow
>they are reimbursed for the average price of the drug plus 6 percent.

I do not understand why anyone thought this was a good idea, or even one that
made sense. What was the purpose here?

~~~
tlb
If they were only reimbursed for exactly the cost of the drug, they'd lose
money on expensive drugs because of inventory costs. Inventory costs include
interest on money for the time they're holding it, damage and spoilage,
security, theft, insurance, etc.

6% is probably a reasonable guess at the average costs. Large, high-volume
operations can make a profit by keeping their costs below 6%, and that may
create a wrong incentive. But the right answer isn't to change 6% to 0%,
because nobody will want to handle expensive drugs.

~~~
yaddayadda
For the most part prescribing doctors aren't the ones who have to deal with
inventory costs, it's pharmacies that have the inventory costs. I've even had
doctors send me to the pharmacy to pick up injectable medication, primarily
because they didn't want to deal with an inventory. So why should prescribing
doctors get 6% of cost?

~~~
tlb
Prescribing doctors don't get 6% of the cost unless they're also supplying it.
Lucentis is injected with a needle into your eyeball, so you probably want
your ophthalmologist to do it in their office.

~~~
aestra
My doctor injects medication into me every few months. I go to the pharmacy to
pick it up first, and then go to the doctor to get it injected.

------
kevinpet
What I found most interesting about the article was the complete lack of any
idea of the patient paying for the drugs. The word "patient" literally does
not appear on the first page, throughout the rest of the article, it only
occurs in references to studies, except on the last page, were we find "many
decisions are guided by whether the patient’s insurance covers the entire cost
or just a portion."

It seems that patients aren't agents who have any involvement in anything, in
the authors world. They're just objects to be pushed around by insurance
companies, doctors, and drug makers.

Regardless of the details of these two drugs, right there you have the problem
with health care in America.

------
mdisraeli
"it’s the same damn molecule with a few cosmetic changes" pretty much tells
you everything you need to know about this article.

As any chemist worth their salt will tell you, small differences to molecules
doesn't necessarily make them just as easily produced. And similarly any
biochemist worth their salt will be able to tell you that small differences
can indeed matter a lot!

Reading the wikipedia article for the more expensive drug
([http://en.wikipedia.org/wiki/Ranibizumab](http://en.wikipedia.org/wiki/Ranibizumab)),
it does appear that there are therapeutic differences between the two drugs in
terms of associated infections.

The real thing, however, to check when talking about medicines is the Specific
Product Characteristics sheet. This is, in essence, what doctors refer to when
looking up medicines.
[http://www.medicines.org.uk/emc/medicine/19409/SPC/Lucentis+...](http://www.medicines.org.uk/emc/medicine/19409/SPC/Lucentis+10+mg+ml+solution+for+injection/)
and
[http://www.medicines.org.uk/emc/medicine/15748/SPC/Avastin+2...](http://www.medicines.org.uk/emc/medicine/15748/SPC/Avastin+25mg+ml+concentrate+for+solution+for+infusion/)
. Avastin is used for a lot more than just eye conditions, it seems, and has
shall we say a number of issues.

Something most people fail to realise is exactly how expensive new drug
development actually is. You've got experimental labs doing in-vivo tests of
thousands of molecules (at least), animal studies to ensure the human trials
will be safe, multiple stages of clinical trials in humans with associated
insurance, etc. The sole means of recuperating the cost of all of this is
through product sales. There are very few actual grants awarded for developing
medicines all the way through to production. No tie-in marketing of lunch
boxes. No crowdfunding from patient groups.

I do wholeheartedly agree, however, that there are perverse incentives on
doctors to prescribe more expensive medication, and the modern pharmaceutical
industry is messed up in so many ways. Most doctors too don't even understand
properly what it is they are prescribing[1], and the 21st century medical
representative system has more in common with jingles and home appliance sales
than the clinical educators of the 20th century.

Disclosure: I have family and friends working in this field

[1] Reasons why people become doctors: money, power and helping people. Good
doctors get to chose two of out of three. And to be fair to doctors, they have
to remember a hell of a lot of academic material in a constantly changing
field, and /then/ have social skills and physical skills to master

~~~
kerkeslager
> As any chemist worth their salt will tell you, small differences to
> molecules doesn't necessarily make them just as easily produced. And
> similarly any biochemist worth their salt will be able to tell you that
> small differences can indeed matter a lot!

As an example of this: thalidomide has two different enantiomers (see here:
[http://en.wikipedia.org/wiki/File:Thalidomide-
structures.png](http://en.wikipedia.org/wiki/File:Thalidomide-structures.png))
one of which is harmless (or at least is until it racemizes) and the other of
which causes severe birth defects. These are literally __the same atoms and
same bonds __with a twist.

If a twist in a molecule makes the difference between a healthy baby and a
severely deformed one, then "a few cosmetic changes" can make a huge
difference.

~~~
silencio
And for a more common situation involving "a few cosmetic changes" that makes
me feel not so bad about talking shit about drug companies, take a look at
levocetirizine.

My doctor tried for a couple years to push it on me while fully knowing that I
would much rather just go to Costco and buy a year's worth of generic Zyrtec
for the after-insurance cost of one month of Xyzal. There is literally no
difference in effectiveness or side effects for me between the two. For many
people there won't be much of a difference.

~~~
jrockway
Tried to push it on you, or prescribed it and you filled it? Often doctors
will prescribe the new drug to help patients save money: the insurance company
doesn't yet realize it's the same as the cheap generic, and will pay the full
cost for you because it's the only drug in its class available. (Buying the
over-the-counter drug, you have to pay 100% of its cost from your taxable
income, instead of paying $7 from your tax-free income. Then again, given a
year's supply of generic Zyrtec is like $20 on Amazon... you'd have to have a
pretty high tax rate for that to make sense.)

Obviously, insurers have wised up to this scheme with the "new" allergy drugs,
but in other cases, it can be helpful.

~~~
silencio
In some cases it makes sense for sure. I'm guessing that or something like
that is probably why Lucentis is also a blockbuster drug. If the price makes
sense then what's the point in thinking any more about it? I would just go
with the most affordable option.

In my case, he prescribed it and I asked for an alternative after a small case
of sticker shock at the pharmacy (and the pharmacist was the one that
mentioned it's practically Zyrtec). The next visit he dumped a couple months
worth of samples into my lap and told me I should just stick with it and pay
for it because it's worth it, so have some manufacturer coupons - you know,
the same doctor that prescribed Zyrtec to me before Zyrtec was OTC, hahahaha.
I'm still assuming that he wasn't after a kickback as much as it was just
sticking with anything that worked at all in the months that I had bronchitis
and sinusitis at the same time (with existing allergies and asthma, it was a
terrible hell). Except he kept telling me to give it a chance after all that
was over. Then I changed insurance plans and he wasn't in network so that was
that.

I think the most unfortunate thing is that pricing is pretty opaque. Outside
of that and a couple other situations, my doctors have been really helpful in
trying to find cheaper alternatives but they don't know what is cheaper other
than having someone spend time with the pharmacist going down a list of
alternatives. Another anecdote from helping my dad: I used to set aside 2
hours every time he got a new prescription from his ophthalmologist. There
were eyedrops that were literally $5/bottle/month, and then there were
eyedrops that retailed for over $500 for a fucking 10ml bottle ~1 month supply
(I'm looking at you Alphagan P). Every insurance company and plan would be
different so someone from the doctor's office had to call the pharmacy and
dealing with this took a couple extra hours on my end. Sometimes some brand
name would be drastically cheaper than the generic (this happened with
Adderall with my old insurance plan). Sometimes the price changed for no
discernible reason (not even like anything to do with deductibles). It drove
me nuts.

tl;dr don't be sick. it sucks.

------
timr
This is hardly surprising, and it's unfair to try to turn it into a problem
with "entitlement programs". There are many examples of this kind of thing --
and private insurers aren't pushing back on the costs, either.

Take the anti-viral drugs acyclovir and valacyclovir. They're both anti-virals
used to treat diseases caused by the herpes simplex virus (e.g. shingles,
chicken pox, cold sores, herpes, etc.), and are both commonly prescribed to
patients of all ages. The only difference between them is that valacyclovir is
a pro-drug -- it metabolizes to acyclovir -- and has slightly higher
bioavailability, which means that patients can take three doses a day, instead
of five. Otherwise, they're equivalently effective medications.

Granted, three doses a day is easier on patients than five doses a day, but
that convenience comes at a cost: valacyclovir costs about five times as much
as acyclovir. Your doctor won't tell you this -- she'll just prescribe the
valacyclovir, in nearly all cases -- and your private insurance company won't
do anything to encourage you to take one drug over the other. About the only
way you'd know is if you tried to buy the drug without insurance, and your
pharmacist told you that you could use this _other, cheaper_ medication to
save a lot of money.

Not only are "entitlement programs" not the problem here, they could actually
be the solution: a single-payer health system would have an economic incentive
to push back on providers, and encourage them to use more cost-effective
drugs. Our current, private insurance system is almost totally blind to cost
effectiveness, because nobody in the chain has any incentive to care. The
final costs of the system get passed back to employers in the form of annual
rate increases, when it's too late to do anything about them.

~~~
hga
Errrm, it's my understanding that "compliance", i.e. people actually taking
their prescribed medicines per schedule, is a _terrific_ problem in the real
world. The payoff in patient health can be substantial; in one area I'm
familiar with, anti-depressants, there's a _strong_ bias towards those that
are normally taken once a day (one of the many advantages of Prozac, the first
SSRI).

So I can see lots of physicians routinely prescribing the valacyclovir ...
although for someone like me, to whom the whole idea of compliance was a new,
almost unthinkable thing when I first learned about it, they'd like go with
the acyclovir (especially after I looked up the drugs in question, read up on
their pharmacokinetics, etc.; obviously I'm a special case, e.g. nowadays I
tell my doctors what to prescribe me for allergies and sinus infections,
having learned what works and what's cheap).

Hmmm, come to think of it, when I got an "early" (age early 40s) case of
herpes zoster (shingles, and, yeah, it's no fun at all, get the vaccine when
you can) in 2003 I was prescribed acyclovir, by a doctor who knew both my
financial situation (not great then) and compliance patterns.

~~~
timr
Yeah, I don't mean to diminish the importance of compliance -- it's a big
problem, especially for things like antibiotics and anti-viral meds. And
certainly, three times a day is a lot easier than five times a day. But as you
imply, you might rationally make a different choice if you (the patient) know
the facts. My point is that nobody has any skin in the game in the current
system -- from the perspective of the decision makers, the costs are almost
totally externalized.

Aside: I also learned about this when I came down with shingles. That was a
bummer (not the least of which because I was on COBRA at the time, and the
insurance company refused to pay the med costs without going through a
complicated reimbursement scheme!)

------
mhurron
But don't listen to those that say a regulated health care system is needed.

These companies are just looking out for their own like good Americans.

~~~
varelse
In the long run, the problem takes care of itself when the patent expires in
2019 in the US and 2022 in Europe.

[http://www.fiercepharma.com/special-
reports/avastin](http://www.fiercepharma.com/special-reports/avastin)

Until then it's off-label usage. When the time comes, expect an absolute
feeding frenzy to make a similar equivalent (with incrementally higher
efficacy or slightly fewer side effects) or an alternative formulation to
regain those patent rights. I would expect Genentech is already hard at work
here.

~~~
mistercow
Except that the problem _doesn 't_ take care of itself. By 2019, the same
company will likely have on the market a new patented drug in the same family,
with roughly the same efficacy as the other two. They can do this pretty much
indefinitely.

~~~
yahoo893
Wrong. Pharmacy doesn't work that way.

~~~
ceejayoz
Yes, it does. They add something like calcium carbonate (tums) to an existing
med and patent the combo, or they find an isomer of the drug. Happens all the
time.

~~~
yahoo893
No, it doesn't. Generic companies can make replicates of the original drug
easily when the original patent expires.

~~~
mistercow
Yes, but those generics will be cheap, whereas the new drug will be expensive.
Since the doctors are reimbursed based on a percentage of the cost of the
drug, they will choose the more expensive one, just like they do now. A cheap
competitor already exists. Adding another cheap competitor won't help when
doctors are incentivized to use the most expensive option.

~~~
refurb
You're forgettingabout the incentives of the insurers. They will be the ones
to require the cheaper alternative, similar to the way many insurers require
the use of Avastin for AMD unless there is a good reason to use Lucentis.

~~~
ceejayoz
> They will be the ones to require the cheaper alternative

They likely can't in this situation, as the cheaper alternative is off-label.

------
shoyer
This article seems to miss the bigger picture -- why is Lucentis 40x more
expensive than Avastin?

The answer is that drugs aren't priced by how much they cost to manufacture a
dose -- nor should they be!

Roughly, they're priced by the cost of R&D (a fixed cost) and the benefit to
patients (a fixed benefit per patient). So it makes complete sense that
Lucentis is more expensive, because the does size is so much smaller. It's
still vastly less expensive to get eye treatment with Lucentis than cancer
treatment with Avastin, which runs at ~$100,000/year.

------
dude3
The Post conveniently left out that the Pharm company found that "Avastin
patients had a 30% higher risk of serious systemic side effects than Lucentis
patients did". Why didn't they include the Pharm company's side?

[http://www.fiercepharma.com/story/novartis-digs-safety-
data-...](http://www.fiercepharma.com/story/novartis-digs-safety-data-avastin-
vs-lucentis-study/2012-05-02)

~~~
alphaoverlord
The article does mention and debuffs it. Its the difference between 32 and 40%
Its based off one study of small sample size and is not biologically
plausible.

>The incidence of what are known as serious adverse events — a catchall
category that includes hospitalizations for any reason — was slightly higher
in the Avastin group: 40 percent vs. 32 percent. The adverse events included
broken bones and urinary tract infections.

“The majority of the adverse events would be difficult to imagine being caused
by the drug,” Martin said. Martin noted that while small, probably random
effects favored Lucentis in some cases and in others they favored Avastin.
Neither should be viewed as conclusively related to the drug, he said. >

------
jheriko
medicine is one of the areas where being economically driven causes problems.

medical research is stupidly expensive and companies need to recover their
costs for their to be progress at all. incidentally its the /only/ valid
argument i have seen for patents. it also explains a lot of the high expenses
involved... its a shame, i feel that this is an industry that desperately
needs to be nationalised because, even with the best of intentions, a business
must be profitable to survive.

we regularly see layers of rhetoric and polical manuveuring attacking e.g.
Obama care, the NHS and similar initiatives and from this i feel we lose out -
they criticise the specifics for a political agenda. imo the spirit of these
programs is exactly right - the problem is always sloppy implementation by
politicians (as with any case where nationalisation is not effective - which
is /provable/ almost in the mathematical sense). We can't expect them to do
well though - they are winners of popularity contests which essentially boil
down to competitions of rhetoric and salesmanship - they have no reason to
have any of the prerequisite skills for us to expect them to do a good job in
that arena - or even leadership in general. it is a massive failing of our
particular flavour of democracy imo.

on the other side doctors are supposed to be bound by the Hippocratic oath.
this utterly rules out not helping people because they can't afford it - and
yet many physicians have to make that choice regularly - which is not just
breaking their word, but against the entire spirit of medicine and morality.

all in all its a horrible situation, but one that i believe is incredibly
fixable... however articles like this are attacking the institutions which
currently allow us to have medicine and portraying it in a way that the common
man will empathize with. its just another pile of rhetoric distracting us from
being productive imo... if you dig into any of the details as other commenters
have mentioned, the factual basis is weak.

------
ajtaylor
I'll take a different angle from most of the comments and talk about the
prohibition of Medicare negotiating the price of drugs. The article talks
about how two other countries have negotiated discounts of 35-45% off the list
$2000 USD price. If you want to help hold down prices, all that's necessary is
to actually negotiate a volume discount with the drug companies. It's
basically an indirect subsidy to the drug companies via Medicare.

------
lazyjones
It's well known that the pharmaceutical industry sends representatives to
doctors to persuade them to prescribe their products. Frequently this is
achieved with special "incentives" (read: bribery). Some doctors around here
have put signs on their doors saying that they do not talk to representatives
of pharmaceutical companies.

------
lr
If this kind of stuff outrages you, please ask your Rep to investigate:
[http://www.house.gov/htbin/findrep](http://www.house.gov/htbin/findrep)

Since we are talking about taxpayer money, this seems like a great opportunity
for a Congressional hearing on the matter.

------
iguana
What isn't mentioned is that these drugs are actually injected directly into
the eye. My grand father was prescribed both, and had no improvement in
vision. When he switched to the expensive one, there were excellent results,
and he can now see again.

------
judk
I thought this sort of thing is what insurance companies are expected to
handle: to advise on cost-effective alternatives for standard diagnosis codes.

~~~
ceejayoz
The article talks about Medicare, and how it's forbidden by Congress from
negotiating prices, among other things.

I'll give you one guess on which industry lobbied for _that_ restriction.

~~~
refurb
The gov't sure as hell negotiates other price concessions from pharma
companies:

1\. Medicare only pays "average selling price" which includes all discounts
offered to physicians

2\. Medicare demands pharma pay 50% of the donut hole gap which is several
billion each year

3\. Medicaid automatically gets a 23% discount on all drugs

4\. DOD, VA and other gov't organizations do negotiation drug prices and they
get a 24% discount on top of that

There is plenty of price negotiations on the gov't side.

------
finspin
In Finland this is handled in pharmacies. Pharmacist will always inform you if
there is a cheaper alternative to the drug you've been prescribed.

~~~
shoyer
Really? Lucentis is injected into the eye by doctors -- it's not something
you're taking at home.

