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Some insurers insist that patients forgo generics and buy brand-name drugs (nytimes.com)
201 points by iamjeff on Aug 8, 2017 | hide | past | web | favorite | 186 comments

I have United Healthcare, and I have to say I've seen this happen to me as well. I'm on a long term maintenance medication, which is delivered by patch. I was on the generic in my previous health plan, so my new doctor prescribed the same generic.

I used the mail order pharmacy and they told me that a 90 day supply would cost $347. I asked why it was so much, and where my prescription benefits came in. They said they didn't cover the generic, and I said well do you cover the name brand one? They said they did, but they couldn't give it to me because my doctor had ordered the generic. If I ordered the name brand, it would be $100 for a 90 day supply, which is a huge difference.

I called my doctor, and got them to change the prescription. None of the people at United Healthcare were offering any of this information, and I basically had to pry it out of them to figure out why they were trying to gouge me. Also, this was their own private mail order pharmacy, so all the money was going to them as well.

Ask a lot of questions before paying a lot of money.

"They said they didn't cover the generic, and I said well do you cover the name brand one? They said they did, but they couldn't give it to me because my doctor had ordered the generic. If I ordered the name brand, it would be $100 for a 90 day supply, which is a huge difference."

3 possibilities:

1. Your doctor wrote "dispense as written" on the script, which barred United from substituting. This is highly unlikely because doctors only do this when prescribing name brand.

2. United didn't have system rules in place to flag this type of thing because there's no financial incentive to do so for United or your employer who is actually paying for your drug. Chances are, if generic costs $347, then brand name costs more. When you pay $100, your employer is still paying the remaining, which could be $250+ When you get generic, your employer pays nothing.

3. United didn't have system rules in place to flag this because they are just incompetent. The fact that they don't cover generic means that your employer is getting rebate from brand. Unless your employer is trying to save a few bucks by intentionally screwing over their employee, United system should've flagged this an simply auto substituted to cheaper alternative.

Either way, unless brand was materially different, United is within legal right to auto substitute without needing a new scripts. In short, they served you a bunch of turd sandwiches.

I'm actually self employed, and I got this health care policy on the health care exchanges - there's no employer in the picture, which is probably why they're trying to shift the cost to me, as opposed to paying for the brand.

So really, without an employer, it's just because there's no financial incentive for them to do so. Actually, it's negative incentive for them, because they tried to get me to pay for something they wouldn't have to pay anything for. Then for dispensing it, they charge me since they are also the pharmacy.

Yes, without employer in picture, what they did was probably deliberate. They also straight up lied to you about needing a new script. I work in the industry and familiar with some of these practices, but this is pretty low.

I understand if you don't want to answer this, but is there a subsity covering part of your plan you purchased through healtcare.gov?

No, I pay the full price myself out of pocket (and write it off on my taxes).

Thx for the response, wondering what UHG's potential motivations may be. I used to work in the medical billing industry, and UHG had a very poor reputation (among major insurers) with the two healthcare management consultants I worked closely with. (edit: UHC-->UHG)

The last paragraph in the article gets to the point:

“There’s only one reason why they’re requiring you to use a more expensive product,” Mr. Frankil said. “Because somewhere down the road, somebody is earning more money.”

The brand-name maker would like the generic market to dry up, so it may be as simple as the brand-name maker selling its product at a reduced price on condition that the insurer cuts off the generics. Given that some patients demand brand-name drugs and some doctors acquiesce, this may be cheaper for the insurer.

My doctor has a straightforward attitude - referring to patients who demand brand-name drugs "I told them 'I take generics. My kids take generics. If you won't take generics, find another doctor!'" (that was before the practice described here emerged. I am sure he has something to say about it...)

I wonder if this is an end-run around my hands-down favorite part of the ACA, the hard limit on the "Medical Loss Ratio" (MLR). Insurance companies must spend at least ~80% (the number varies by plan type, but call it 80%) of premiums on medical expenses, and if they don't, that's when you get those refund checks in the mail. (In the 90's, you had a few insurance plans with >90% MLRs, but by the early 2000's the average had declined to 70%, and you had some companies selling plans to college kids with a 10% MLR.)

This is overall good, because insurance is one of the few industries that benefits from monopoly conditions (bigger risk pools are better), so you want a hard cap on how much money the monopolies can extract. But maybe demanding non-generics is a way to increase "medical losses", which in turn is a way to increase their permissible profits?

Interesting, or a similar phenomenon to situations where in order to maximize deductions you might want to increase charitable contributions, better to give the money to a friend non-profit than Uncle Sam

Generic neurological drugs are not reliably consistent. The allowed variations and additives can and do play havoc in some people. Even something so simple as coloring can be a problem.

United didn't have system rules in place to flag this because they are just incompetent.

I could definitely see some junior dev writing "if (isNameBrand()) { lookForGenerics(); }", even if the requirements doc was less specific and just said "look for lower-cost alternatives". Catching that sort of extraneous assumption is one of the things that comes with experience.

I actually think the first possibility is more likely than you think. OP said he was previously using a generic patch. Patches can have different dosing instructions, and when switching between generics and name brand the doctor may want to give additional instruction. They may have written DAW to try to continue the same therapy without additional instruction. Usually not a problem, but OP switched plans.

The fact that they wouldn't dispense an alternative when asked until having the doctor update the Rx kind of supports this as well.

It's she actually. And the patches are equivalent in terms of dosage, and I've been on both. They even look exactly the same.

The only thing that might be different, as far as I can tell, is the adhesive they use for the sticky part.

Apologies for making the assumption :-)

It's possible there are different alternatives that have different dosages. If you really wanted to find out though, you could always ask your doctor. Dispense as written can be used because the doctor gets kickbacks, but there are frequently more innocent reasons for it. Perhaps the adhesive isn't as effective, but ultimately there are any number of things that can differentiate generics from brand names or other generics. Pills tend to be more similar, but even then there can be differences despite technically being the same drug.

I have United Healthcare and when I first switched to theme I was informed by my pharmacy that UHC requires one of my prescriptions to be written to require name-brand-only before they can fill it. This often leads to problems filling it because of supply, and the copay is 3x higher, and if the doctors office makes a mistake I have to go back to them to correct it (it's for Adderall, so the pharmacy and doctor cannot exchange the prescription over the phone or computer--I have to do all the back and forth in person with paper).

This is, obviously, quite irritating, not to mention expensive.

I have UHC and take Adderall XR. I have never had an issue because of how the prescription was written. My doctor has always written it for Adderall XR with generic substitution allowed. This allowed me to get the generic version prior to switching to UHC and has allowed me to get the name brand without issue after switching to UHC. Even if the way your doctor sometimes writes the prescription causes an issue. It seems this is easily preventable with minimal effort on your part. Just remind your doctor how it needs to be prescribed and double check the prescription before leaving the office. My co-pay for Adderall XR with UHC is the same as my co-pay previously for the generic version. Maybe I was getting gouged before.

> it's for Adderall, so the pharmacy and doctor cannot exchange the prescription over the phone or computer--I have to do all the back and forth in person with paper

This is somewhat off-topic, but I've always thought that the requirement for using a paper prescription for controlled substances was counter-intuitive. To me, it would make more sense to do this electronically and not involve the patient at all in the transfer of the prescription itself. Plus, the electronic system should be able to verify the identity of the prescribing physician and dispensing pharmacist to both parties involved as well as a central authority if necessary, which is more difficult to do with a paper prescription.

>This is somewhat off-topic, but I've always thought that the requirement for using a paper prescription for controlled substances was counter-intuitive

Is this a state-specific requirement? My wife is on a few controlled substances and we never receive paper scripts, but instead her doctor sends it in electronically and the pharmacy calls us when it's ready.

BriovaRx I assume? These guys are the worst. OptumRx (might be who you have through United as well) screwed me over because no one ever explained to me what the hell a "specialized" medication was.

I was put on a $drug and so when asked where I wanted to fill it I told my doctor to send it to my local Kroger Pharmacy. I went and tried to use my insurance but it wouldn't run for this $drug. I called OptumRx (the number on my healthcare card) and they said it should work. I gave them all my info, they assured me Kroger Pharmacy was In-Network, and they had me stand in line again so that they could talk to the pharmacist. No one could figure out what was wrong so the pharmacist gave me 3 pills to get started and OptumRx told me it would be cleared up by tomorrow and they would call me. Day 1, no call. Day 2, no call. Day 3 I call the pharmacy and they say they haven't heard anything from OptumRx, I called OptumRx and they finally realized that this $drug is a special drug that can ONLY be filled by their online pharmacy BriovaRx. I get transferred to BriovaRx and they say they can mail me the drug in 2-3 days and I tell them that's not going to work because I took my last pill today and there aren't supposed to be any breaks in the medication. Finally they cave and call in an "override" so I can get it from Kroger this one time.

They also fucked up a delivery once and told me they couldn't send more pills until they figured out what happened to the last package (which could take days) and I was 1 pill away from being out. I had to fight my way through people telling me there is nothing that could be done about it until finally, again, someone called in an override. Mail order may be nice and all but when I can't re-order until I'm less than a week out and shipping doesn't always work as expected it's a huge PITA and a big stressor. I order EVERYTHING off Amazon so trust me when I say I prefer the idea of mail order but when I need a medication I want to be able to walk down to the Kroger Pharmacy and fill it instead of waiting for something that might not come on time.

There was a recent, interesting discussion on econtalk that I think I'd related to this. In order to get a generic approved you need to proof bio-equivalence. To do that you need three original drug. The original creator of the drug has interest to delay this as long as possible. So they use the special drug thing to make it really hard for their competitor to get the drug. Sounds totally insane but apparently is common now. The original intend of the special drug thing was to protect people from more dangerous drugs that you need to be well informed about.

> To do that you need three original drug.

Can you rephrase this? I can't grok what you mean.

Sorry, phone auto correct. As someone else pointed out it should be "the original drug". You get both drugs and show that they are the same for the body.

I think if you replace three by the, makes sense

Mail-order pharmacies are the worst. I understand what they're trying to accomplish WRT costs, but I've never encountered one that could actually deliver consistently and on-time. Frequent delays for no good reason, no express shipping, lost paperwork, etc. It's a mess.

Express Scripts is pretty bad as well. I've lost count of how many hours I've spent on having to jump through the oddies of mail order pharmacies...

Well you saved me. I was going to do a 90 day med with them to save a trip to the pharmacy.

I would still check prices on your pharmacy benefits site between mail order for 90 days and a local pharmacy. The mail order pharmacies are frustrating, but typically you pay less for a 90 day supply.

This might be a stupid question, since I don't know how the US system works - if you have health insurance, why do you have to pay anything for drugs "covered" by your insurer? If they cover a medication, why is there anything left to be paid by you? Do you also have to pay if you have any treatment that is "covered" by your insurer?

As an example, I have a 4500 dollar deductible. That means until I pay 4500 for prescriptions, doctor visits, labs, ER visits, etc., insurance pays nothing, though I do get their negotiated "discount" from the provider. After that, the insurance pays 80% of the cost until I have paid out some even larger number, at which time they pay 100% until January rolls around.

This is a pretty normal plan, and the type the guy you're responding to is describing; older plans often have much lower deductibles and have copays, though premiums tend to be higher, but one they're hard to find now.

It's very easy to meet a 4500 deductible. I've already done it for the year without any major health events.

For anyone in Europe in a normal healthcare plan, US healthcare is just a fucking joke.

Switzerland has the same system with deductibles and after that you need to pay 10% with a maximum of 700 per year. Cost is about 220 per month for a insurance with 2500 (max allowed) deductible and 320 per month for the one with 300 (lowest allowed) deductible.

I mean, the reason I asked is that I can't imagine paying anything for any treatment or medication. The thought that you pay for private health insurance and yet have to pay anything for medicine/treatment is super weird to me.

It's not arbitrary, the deductibles and copays push down the monthly premiums.

Under the ACA, the cost sharing is standardized, so it isn't simply a matter of the insurance company enriching itself or anything like that. This document discusses how the standardization works: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8...

For anyone here in the US, US healthcare is just a fucking joke.

The idea is because you have to pay a little bit out of your own pocket you are less likely to run to the doctors and get a prescription when nothing is wrong. Since it is your money that you could spend on something fun instead of a pill you will ask do you really need to buy the pill, or will a cheaper pill work just as well. Note that the above is the idea - there are various problems with it, but the idea makes some sense.

There is a real problem with some people going to the doctors and demanding a pill to fix some problem, doctors get tired of seeing this person and prescribe something relatively harmless just to get them to go away.

Doctors used to prescribe antibiotics for viral illness as well because people expected a pill from the doctor.

Some old people have no friends left so talking to the doctor is the only social life they have.

Do not confuse the above with with cases where there is something wrong and the doctor cannot figure out what.

Geezus, is that really the reason for co-pays?

The co-pays for some drugs can get pretty steep for people on fixed incomes like social security. If the only reason is to keep people from nagging the doctor, you'd think that the co-pays would be fixed instead of varying wildly depending on the drug.

Health insurance plans have varying coverage for drugs (and those plans can vary a lot state to state), so that's going to depend on the plan. Decent plans typically pay everything but a very small charge. Average plans often have limits to routine prescription drug coverage in a given year.

A medication I took last year cost around $90-$100 or so. The insurance covered all but $10 of that.

Many have large deductibles as well, so it's common for yearly medication costs to be out of pocket.

I had a similar situation with my mail order pharmacy. Ordered a 90-day supply of maintenance medication, was charged brand rates against my deductible. They dispensed the brand rather than the generic. Asked why, they said, well, we have a deal with the company, you get brand drugs at the cost of the generic co-pay! They neglected to understand that some of us don't have co-pays for Rx, and pay the actual cost. Solution? Go to Costco, get 30-day subscription, pay pennies per pill.

Just because it's their own private pharmacy doesn't necessarily mean they follow a different set of rules. The PBM probably has that pharmacy set up like any other and treat it as a preferred pharmacy with internally negotiated discounts.

The big secret is that bio-equivalent and generic drugs sometimes aren't effective!



Frustrating that the article doesn't point that out. These new formulas do not need to prove they work, they just have to prove that their active ingredient is the same after the patent expires.

Haematologist here - your references don't support your argument.

Here is the referenced ASH abstract from 2015 [1]. It doesn't show any statistically significant finding. Even if it did, it is simply an observational study with few patients - there may be other confounding factors at play - you would need a randomised control trial to find out. I doubt that is going to happen. Also it should be noted that all authors disclose receiving payment from Novartis, and there isn't a follow-up paper by the same authors, from my brief googling. Actually, the figure looks very strange - they have an n=11 according to the number at risk along the bottom.

A published paper from Turkey compared 36 on brand versus 26 on generics. They didn't find any differences, but noted this[3]:

  Among our patient cohort, the generics were at least non-inferior to the original molecule regarding efficacy and tolerability when used in the upfront setting, as well as when used subsequently (Eskazan et al, 2014). Prospective randomized trials with larger number of patients are needed to address the efficacy of generics of IM in patients with CML.
The chemical structure of imatinib, C29H31N7O isn't that complicated[2]. If a medicine can be proven to contain the same amount of the active drug, particularly when the structure is relatively straight forward, I'm inclined to believe that.

The story is a bit different for more complex treatments (i.e. antibody treatments like rituximab - C6416H9874N1688O1987S44) and for drugs with various preparations (especially inhaled or slow-release versions). In those cases you have to check the active ingredient and formulation - in which case the Brand usually does matter.

[1]http://www.bloodjournal.org/content/126/23/2778?sso-checked=... [2]https://en.wikipedia.org/wiki/Imatinib [3]http://onlinelibrary.wiley.com/doi/10.1111/bjh.12937/full#bj...

It's very frustrating. I know people who cannot tolerate some of the fillers and other additives put into some medicines. They end up trying various generic and non-generic brands until they find one they can use. In most cases, the name brands seem to use better quality ingredients because those are the most likely to be tolerated. It's amazing that the FDA requires an ingredients list on food but not on drugs.

Additionally, the manufacturing standards can really vary. If the active ingredient is measured in micrograms and the FDA allows 10% variance, then you can be really screwed if the generic manufacturer is sloppy, while the name brand is manufacturing to tighter than FDA specs. A 10% difference could be the difference between one dose and the next higher dose. Seen this too.

Almost everything in this comment chain is incorrect. Manufacturers do list all ingredients including fillers and inactive ones. Ask for the "package insert" and the pharmacy will give you the sheet with that info.

Also, brand name and generics are tested to the same tolerances. If the generic is allowed 10% margin the brand is too. In fact, sometimes they're made on the same production line. A few years back when generic Protonix came out it was a huge issue, as it was extremely easy to mix up the "brand" and "generic" because they looked identical and came in similar packaging. I remember hearing about pharmacies getting fined for supposedly mixing them up. If there is any chance of a mixup between brand and generic (missing DAW is a common typo) you had to throw them away because there was no way to tell them apart.

Something else you overlooked, related to the above, is that "Brand name" companies typically own as least one subsidiary that produces generics. For example, GreenStone is 100% owned by Pfizer, so i have doubts their generic products could be any different.

I'm not normally a dick on HN but I don't appreciate people blowing facts out their ass when it relates to common misconceptions. The drug companies want you to believe generics are inferior, and they spend more on marketing than drug research. You should speak to some pharmacists if you want honest opinion on the matter. They're easy enough to talk to and I think you'll find that the vast majority share my opinion.

Avoid generic drugs if you can. I've got lots of first-hand experience in this matter. It's not a matter of efficacy. It's a matter of quality. That's all I will say.

I am going to strongly disagree with you, it seems as if you are guilty of blowing facts “out of your ass,” we the the implication that bioequivalence is the same as therapeutic efficacy. Because that isn’t always true, especially in psychiatric drugs. It could be true in many cases, but it isn’t always true – which means there is sometimes a clinical justification for non-generics.

Here’s one study addressing that specific issue:


I know a guy with for-real celiac disease. Although the active ingredient may be the same, not all generics are certified as safe for celiacs thanks to the additional padding in the pill.

Generics and brand name are NOT always equivalent depending on the drug and condition, and spreading this lie is incredibly dangerous to many people.

This is what happens when CEOs, politicians, and pundits are deciding health policies rather than the properly informed health officials.

Now if the insurance policy would be that a doctor must write medical necessity for avoiding the generic, go for it. But mandating that people can only take generics will cause harm.

Everything is measured very accurately. The 10% variation is in bioequivalence, not in the amount of the active ingredient.

For people taking drugs with a narrow therapeutic index, though, that variation is huge.

Correct, and bioequivalence is not the same as therapeutic efficacy.

Has there been a study that established that the drugs with the same active ingredient don't perform as well?

Regulative approval of a generic drug is given by the FDA on the therapeutic effect of the drug, which must be within a 90% confidence interval of 80–125% based on the original. The FDA evaluated 2,070 studies conducted between 1996 and 2007 that compared the absorption rate, and found that average difference between generic and brand was 3.5%, comparable to the difference between two batches of a brand-name drug.

Some comments in here talk about Active Pharmaceutical Ingredient or excipients, but a generic isn't given approval based on their active ingredients. This is one of the common objection given to the patent model for drugs, in that generics still need to show that their version with their unique combination of active and excipients have the same therapeutic effect, which normally means that they need to conduct new studies. The only way you can "copy" a drug is if you make a identical copy in every aspect, including the excipients, and the patent don't include enough information to do that.

That's not correct. To get a generic approved you don't have to show a therapeutic effect. You only have to show bioequivalence: a similar blood concentration time curve for the active ingredient.


If the therapeutically value of an excipient is that they change the absorption rate of the active ingredient, then that effects the bioequivalence of the drug. For example, comments in this thread refereed to different sized particles in inhalers which can have a direct effect on absorption rates.

If we disregard the therapeutic effect from the rate and extent that the "active ingredient or active moiety in pharmaceutical equivalents or pharmaceutical alternatives" reaches the site of drug action, what is left to change the therapeutic effect?

The point is that you don't need to show that the therapeutic effect is the same, you need to show that you expect the therapeutic effect to be the same. The trials required to prove the latter are orders of magnitude simpler, faster and less expensive.

Yes, there's more to a treatment than the API (Active Pharmaceutical Ingredient) which is used to prove bioequivalence. The excipients aren't typically considered relevant, especially when they're on the GRAS list.

One of my former colleagues once made a "drug" where the excipient actually was therapeutically valuable while the listed API was barely better than placebo. Luckily we didn't submit it for approval.

>One of my former colleagues once made a "drug" where the excipient actually was therapeutically valuable while the listed API was barely better than placebo. Luckily we didn't submit it for approval.

That seems... ridiculously illegal.

Why should it be illegal? The submission process would be the same. The reason I sail "luckily" was just that it would be complicated.

I believe there are some topical OTC drugs that work this way :-(

Or did you think making unlicensed drugs is illegal? Of course it isn't -- that's what drug development IS. It's not legal to give such a drug to humans without a valid IND that hasn't been rejected by the FDA but formulating, doing in vitro testing and animal in vivo testing is all perfectly legit.

There are studies showing that some generics don't perform as well as the brand name. Different formulations of the same drug (e.g. extended release medications, different sized particles in inhalers, etc) can have vastly different effects.

Yes, in the specific case of Valproic Acid, a powerful mood stabilizer used for schizophrenia. The generics are different salts, metabolize differently, and different patients typically end up preferring one. If you like one of the two generics, great! If your body best tolerates the name brand... oops.

Yes, the coating on extended release drugs can be very sophisticated:


It should be noted that inn that article, the FDA concluded that this meant that the two drugs were no longer bioequivalence. At that point, you don't have a brand and a generic drug but rather two different drugs that just happen to have similar ingredients.

The article do bring up a major issue when the FDA changed their decision in regard to a generic. The market and even the FDA itself is having a problem to address the problem. The doctor is quoted: “If the F.D.A. rules it’s not the same, how can it be sold? I don’t understand the rationale for that happening.”. It is indeed odd and a major complaint about how the FDA managed this case.

I am not aware of any studies on the subject, but from experience I can say that most generics don't perform as well.

What sorts of drugs treating what sorts of illness? My employer (Europe based) does work for pharmacies and they actively push customers to choose generics[1] because it's cheaper for the customer and the markup is higher (in price -> sales price = greater margin on generics even with a lower sales price than the non-generic). These are long established companies with vertical integration throughout the manufacturing and supply chain.

This is a strictly regulated industry in Europe and I don't see them getting-away-with-it if there were health issues for the patient. I'm surprised to see so many comments here agreeing with the notion that generics are of lesser effect.

[1] prescription drugs, not over the counter paracetamol.

It's likely a placebo effect.

I'm not saying they are exactly equivalent -- things like particle sizes, buffers, release speed, etc (which are often different in different formulations) are known to make a difference.

It is, however, extremely unlikely (to the point of impossibility) that every single brand name is better than every single equivalent generic. I have anecdotal evidence about a specific generic working significantly better than a related name brand for a specific person.

There are specific studies showing a specific brand name is better than a specific [set of] generics. In the few cases I looked into it, that study was financed by the brand. They wouldn't publish a result saying the generic is better if that was the conclusion (and it's usually possible to p-hack a favorable result). I am not aware of generic manufacturers commissioning a study either way.

I can accept a "75% of brands are better than generic" if it came from a well defined study. It's statistically impossible that "100% of brands are equal or better to generics".

Agreed. In the case of the drugs mentioned in the article (ADHD), the generic equivalents of the extended release aren't as good and/or potent as the brand name. This sucks because the generic drugs are so much cheaper, even with insurance.

Europe is strictly regulated, yet those regulations, at least in France allow homeopathy to be prescribed despite absolutely no effect beyond a placebo. Almost every pharmacy in France is loaded up with homeopathic nonsense despite the “regulations.”

On the other hand, the placebo effect can be pretty significant, and sugar pills have no side effects.

So homoeopathic remedies could be a useful thing for doctors to prescribe to people who think they need a prescription but don't actually need one (certainly much better than antibiotics, which I'm pretty sure have sometimes filled this niche in the past).

Isn't that the right way to do it? Regulate against harm and leave the free market to sort out the nonsense? If someone wants to burn incense then let them.

I had specific examples of ACE, diuretics and PPIs generics in mind.

The difference in effectiveness comes from differences in manufacturing. Drug manufacturers typically don't test the effects of drug manufacturing on performance. Because of this, generics can sometimes perform worse.

But, it seems likely that this effect could lead them to sometimes perform better as well.

This is especially true with generic versions drugs like Adderall xr (and SSRI's), is that the potency can be up to 20% less than the brand name.

You guys have the most bonkers health system anyone could imagine. 1/6 of your economy goes on "health care", but most of that doesn't actually contribute to your health, it gets skimmed off by insurers, drug companies, individual practitioners, hospitals and lawyers.

Sooner or later you are going to wake up and realise that a government-run single payer scheme is the only way to go.

I've yet to come across a health insurance scheme that I'd approve without any reservation.

The British NHS that you obviously praise as the single solution is also not without its flaws regarding quality and waiting lists. An acquainted Iranian surgeon who works in England under the NHS remarked that he'd rather fly to Iran in case he should ever get a surgery because the infrastructure is more up to date and the surgeons equally well trained.

The Swiss healthcare system, which I'm more familiar with (universal healthcare, with health insurance being compulsory, while the insurance companies are still private), is also not devoid of flaws. The assumed competition among the insurance companies is not working at all, resulting in rising costs since years.

Is being devoid of flaws really the standard a system should be held to? Is approval without reservation the only threshold for approval?

The NHS and Swiss systems aren't flawless, they have problems and mistakes get made, but the US system is just appalling by comparison. Things that would be considered utterly unacceptable aberrations and be immediately fixed in those systems are routine occurrences in the US with no sign of them ever being addressed and in fact entrenched interests actively working to ensure that they aren't.

Oh no, being devoid of all flaws is definitely not a realistic requirement for approval. I was merely disagreeing with the original comment, which made a very absolutist claim ("a government-run single payer scheme is the only way to go").

All systems have flaws. You hear about flaws in the US system, but they are not nearly as common as you think they are, at least not in my experience.

> at least not in my experience.

I'm glad you're here to speak for us all.

I hope you never have to deal with anyone in your family being admitted to inpatient or residential treatment. As if severe illnesses weren't enough stress on the family, having to immediately come up with your insurance's out of pocket maximum deductible and then spending all of your free time on the phone trying to find ways to keep up the coverage can just push you to the limits.

There's nothing worse than the look on a doctor's face when he's trying to be optimistic while telling you that your kid must be discharged because the insurance company's doctor has deemed them better and is denying claims and you can't afford the $2400 a day it costs to keep them there.

Curious about your reservations about Canadian-style single payer, where hospitals and doctors get reimbursed by the government but are otherwise independent. IMHO it's the best solution, but I acknowledge my own bias since I grew up there.

The wait times seem insane. For things like seeing specialists or having an MRI, the wait time seems to be 30-40x that of the US. Maybe more.

A very recent example from me, I had my first appointment at an NHS physio scheduled 4 months after my shoulder dislocation, which is a full month after I already finished recovering by going to a private physiotherapy clinic.

after I already finished recovering by going to a private physiotherapy clinic.

So, you're saying the method generally used in the US worked for you, and treated you faster.

Unfortunately, at a cost. But I'm pretty sure that's the way it works.

A same-day appointment to a family clinic (Of which you'd already have an association with - I only say it like that because I don't know of a similar practice in other countries) would get you in and out within an hour. Cost is dependent on your insurance, but probably a $30 or less (even $0) visit.

There is NO perfect healthcare system. But I feel, its fairer to consumers in Switzerland and the UK. Its kind of turned in to a sick (excuse the pun) joke here in the US.

> " it gets skimmed off by insurers, drug companies, individual practitioners, hospitals"

7% goes to the insurers and it's not like there aren't equivalent workers doing much of the same work in your healthcare system for similar costs. Maybe it's slightly more efficient, but not by much.

As for being "skimmed" by practitioners and hospitals... that's a weird word to use, since they're just being paid for their services.

You also have to understand that, since you don't experience the US healthcare system directly, the only thing you're going to read is people complaining. The wait times for many services in the US are vastly shorter than they are in government run systems. For an example, same day MRIs are available in some cases or with a day or two wait in most cases.

The short wait times are because of the higher costs/smaller number of people having access to MRIs. It's a tradeoff, and honestly I don't think it's worth it.

The point is that we pay more and actually get things for it. I think a lot of the people commenting from outside the US think we pay more and have a lower level of service than they do, which is incorrect.

That is true, but we also get a lot of things we don't need because the provider knows that insurance will reimburse it. My wife spent some time in the hospital recently and the number of tests they performed was truly staggering. When I asked the technician performing one of the scans what it would show, his response was "probably nothing, but we just do it because we can."

I contrast that with my experience in my home country when I ruptured my ACL and required surgery. I visited the specialist who immediately diagnosed the problem after a quick exam and told me that we could do an MRI but that would be a waste of time as it wouldn't reveal anything we didn't already know. I was booked in for surgery the next day with a minimum of fuss.

I totally agree with everything up to the last sentence. State can be a horrible manager too, trust me I am from Europe. Is the problem not about lack of competition and all kinds of barriers?

States can be horrible managers too, trust me I am from the US.

> Sooner or later you are going to wake up and realise that a government-run single payer scheme is the only way to go.

But it's not. Just look at Germany, we have universal and not too expensive healthcare without a government-run single payer scheme, but instead a mix of well-regulated public and private health insurance companies. That's also a path the US could take instead going all the way to the other extreme of a single player system.

I wonder if the guy in the article has considered buying his drug without insurance? In the case of the generic for Adderall XR it is about $70 with a GoodRx coupon at Walgreens, which is less than the $90 copay to get the brand drug with insurance.

Even if your insurance company lets you use generics, it is a good idea to take a look at GoodRx, and take a look at Walmart.

I've had generics where through my insurance my out of pocket was a $20 copay, but when I checked GoodRx there was a $12 coupon. I've had other generics, again with a $20 copay if I got them through insurance, where they were $4 at Walmart with no insurance or coupons.

This is good advice, though the article also mentions that self-paid drugs don't count toward deductibles. In addition to shopping around, patients should calculate their deductibles and estimate how that might impact their spending.

...which is a messed up, Byzantine system. I'd love a single payer system just to crush this inefficiency out of the system and make patient's lives easier. I would have thought healthcare is all about saving lives but in the U.S. it seems like a dirty busy.

I'd love for us to so some market-based reforms to the current system before we blow it up - I concede that Single Payer is likely the only workable answer in the end.

We need to do things like tort reform, the current system presumes that a doctor making a mistake is an extremely rare thing - its not, doctors are human like any other mechanic. Instead doctors over diagnose, and over treat out of fear of liability (which in most states is unlimited). we could limit liability to 2x the actuarial predicted lifetime earnings potential, and limit damages for pain and suffering to 1x that.

We need to allow insurers to pool together to purchase drugs to force the price down - medicare should also be unshackled and be allowed to negotiate pricing on drugs as well.

We should require cost transparency in healthcare - try asking how much a procedure is the next time you go to the doctor, you'll get a bunch of blank stares. People cant make reasonable choices if they cant perform a cost benefit analysis.

Those changes alone - while they may not reduce costs would stop the increases from occurring as quickly.

try asking how much a procedure is the next time you go to the doctor, you'll get a bunch of blank stares.

That's probably because the people you can ask who fully understand the procedure you need don't know what the prices for you are or everything you're going to need, and the people who know the prices aren't doctors and couldn't determine what exactly the procedure will entail. This is by design, of course, but it means that the people you might try to get a price from aren't able to tell you, even if they really want to.

Take your car to a mechanic, and ask how much a repair is before they look at your car. They can tell you typical costs, but can't tell you what your repair will cost yet. So you let them look the car over, then come back to you with an estimate. But that's still not the final cost, because once they start working something else might come up, and they'll have to stop to talk to you about the additional work. You don't know the final cost until all the work is done. That's the way it is with medical procedures too, except most of the time you can't stop midway through to discuss options and costs when something unexpected happens. The doctor just has to take care of it, and let you know about it afterwards.

Actually a lot of places use flat-rate pricing, where they charge the same rate regardless of how long it actually takes: https://www.aaa.com/autorepair/articles/auto-repair-labor-ra...

If a doctor wants to give me a vaccine for something, and I'm paying cash - they should be able to tell me how much it is. They can't. My mechanic can tell me how much a new alternator is and labor without looking at my car.

Yes, they should be able to tell you, but they can't because they don't know. There is a secret list of prices that are over-inflated which is used to send claims to insurance companies, with the understanding that the insurance companies will reject these prices and "allow" lower ones so they look like they are saving the patient money. The insurance company pays some portion of that, and passes the rest onto the patient. That's the number most patients want to know when they ask how much something costs, but the only way to find out is to submit the claim.

If you're paying cash, you're going to get charged that over-inflated price. It's up to you to negotiate a reduced "allowed" price, like the insurance companies do, except you have no clout. You're also not allowed to know what those prices are; they're secret because if they weren't the whole scam would be a lot more obvious and would probably fall apart. (Eg: get challenged in court)

Adam Ruins Everything - Hospitals - https://www.youtube.com/watch?v=CeDOQpfaUc8

Its an eye opener.

Yep, just saw that recently. I kind of knew how it all worked before, but he explains it well.

Building on your car analogy, many auto repairs are common enough that their prices can be listed on the menu. Oil changes, tune-ups, tires, brakes, etc. Known quantities and easy to price. I'm sure the same is true for many non-emergency medical procedures. I don't understand why a doctor can't tell me how much it costs to put a broken arm in a cast, clean out earwax, or treat a rattlesnake bite. Well, actually, I do understand--there is a gravy train of money that comes out of hiding the expense of a service from customers until after the service is rendered.

This place in Oklahoma has there prices listed: https://surgerycenterok.com/pricing/.

I'm sure there could always be complications but there are supposed to be laws in place to stop hospitals from price gouging.

That's great (really) but also see: https://surgerycenterok.com/pricing-disclaimer/

Those prices don't include a bunch of things you'll also need, which makes them a little misleading. Some of those things are predictable, and some, like your housing costs for the duration of your recovery, are not. In a typical hospital setting you're paying to stay in a hospital bed, and they can't tell you how much that'll cost ahead of time.

It's probably a lot easier to determine all of these costs on average rather than per-patient. Medical staff could be paid a salary, and hospitals/etc could set a budget based on average costs and workloads. Then a single-payer system could collect the money needed into one big pool and pay it out based on those budgets.

Yeah, when it comes to really expensive stuff they'll know the minimum, because then they have their own incentives to make sure you can pay, and will be in a financial position to be able to do the post-procedure upkeep. This is especially true when it's stuff with scarce resources like transplants. It's gonna cost a fuckload, you'll have a lot of recurring costs, and they're going to evaluate if you'll be set up for success or not because otherwise there are other people who could use the organs.

There's a whole host of tests and services where price transparency would be easy. Billing simplification too (if the hospital picks the radiologist, they should pay the radiologist out of the fixed fee they charge for the xray...)

This is a great point to make too - if the hospital chooses who renders me service, I shouldn't be getting a separate bill from them.

For the most part, generic drugs are cheap. It's patented drugs and out of patent drugs with only 1 producer that have high costs. Widely used drugs that aren't protected by a patent are pretty inexpensive.

I don't believe there is a functional pure market solution to health care in the world and I don't believe there ever will be.

The companies in question own system you almost can't reform it without first literally lynching the fat cats that run it.

We MIGHT be able to render it obsolete with a single payer system that actually takes care of the citizens.

I dunno, pharma companies paying middlemen to screw over consumers sounds like a pretty typical market based solution to me...

Would single payer cover prescriptions though? Canada has single payer, and you still have to pay something whenever you get a prescription at the pharmacy.

It could. In France (which has a mixed system), single payer cover around 70% of prescriptions costs. And you usually have an additional private plan that will cover the rest (and if you're too poor to buy one of these plans, you can be eligible to get it from the state).

The NHS covers almost all drug costs. In Sweden drugs are free for kids under 18, and others have a yearly cap at ~$200 for drugs, at which they become free (partially subsidized a bit before that).

In Austria prescriptions are coveres but you pay a flat fee if the price of the prescription is higher than that flat fee.

My old plan copays didn't count towards the deductible though, they were totally separate. Is that uncommon?

Let's see. Under single payer system, it's illegal to purchase medicine or health care. Only the government can do it. The government does not get sick, and so is primarily focused on cutting cost. Government picks generic drug that works for most people and has no incentive to worry about the 5% - 10% of people it doesn't work for. Oh, well.

This is pretty much what we have now, except with an oligopoly instead of a monopoly. Not really seeing how going even more in the direction of a monopoly helps.

When people can make choices, thats when things change. People actually get sick, so paying for healthcare is more than just a cost, it can have a value as well.

At least with the current oligopoly system, there is a small amount of choice, and you can choose to purchase a drug on your own if what your insurer has on offer does not work or is more expensive. We should be going in the opposite direction - away from monopoly instead of towards it.

Instead of a single payer, we should have a single market.

> Let's see. Under single payer system, it's illegal to purchase medicine or health care. Only the government can do it.

No, Nearly every single payer system allows you to purchase extra health care, over and beyond what the single payer system provides.

In Canada, as just one example, this is sometimes called "supplementary health insurance". See https://on.bluecross.ca/health-insurance/health-insurance-10... for an example

> Government picks generic drug that works for most people and has no incentive to worry about the 5% - 10% of people it doesn't work for. Oh, well

Generally, this isn't true either. Government picks generic drugs, because it frees up the most amount of money for them to treat other people with.

But if the government covers medications and there's a real medical reason to need a name brand drug over a generic, they'll usually prescribe you the name brand one automatically. Here's a list of that happening in the UK, for example - http://www.nhs.uk/Conditions/Medicinesinfo/Pages/Brandnamesa...

And of course, as always, your still welcome to buy any name brand drug yourself, if you like.

"Under single payer system, it's illegal to purchase medicine or health care."

Total utter FUD. It's legal and normal in each of the 3 countries I've lived&worked in with a single-payer system. You seem very misled.

It's not illegal to purchase medicine or healthcare under most single payer systems.

>Let's see. Under single payer system, it's illegal to purchase medicine or health care.

I stopped after reading this.

How on earth would you outlaw purchasing healthcare? I hope these aren't widespread beliefs...

"Under single payer system, it's illegal to purchase medicine or health care." <2 mins of googling, can easily prove you wrong on this. I personally know from experience you are wrong.

I've saved $3/pill (75%) with a GoodRx coupon. Blink also provides a similar service. But how insane is it that I have to not use my health insurance to buy a health product at a good price?

From the article:

> Then, in 2014, her pharmacist told her that her insurance plan would cover only the brand-name drug, which cost her family some $50 more a month than the generic. If she paid for the generic herself, it would not have counted toward her deductible. Ms. Freundlich complained to her insurer, UnitedHealthcare, but could not get a clear answer.

GoodRX coupons are a come-on. I've had one long out of patent drug jump from $14.77 to $100.58 this year. My doctor was amazed at this. (I just sent that info to the NYT; they have a form for this in the article.)

GoodRX is just a free pharmacy benefit manager. They are relatively up front about it:

How does GoodRx make money?

GoodRx is free for consumers, and we do not require that you create an account to search for prices and receive discounts.

We do not collect your personal information. We make money from advertisements on our site and referral fees.


They might offer coupons in addition to that (I don't know), but they primarily negotiate prices for a formulary. So those prices aren't going to be one time coupon type prices, they are going to be the price they have negotiated with the pharmacy in question (which may indeed change as they renegotiate).

Hi there - a few corrections:

1) We're not a pharmacy benefit manager; we just list prices and available discounts.

2) We're constantly looking for new prices and lower discounts. While prices don't generally change as much as mentioned above, they do sometimes change. I believe we're familiar with this case, and this was the removal of a price by one pharmacy benefit manager. We're sorry it went up, but it was only because this price has been adjusted by the pharmacy benefit manager, not because we're up to anything evil.

Yeah, around 2007 Target announced they had reduced a whole bunch of generic maintenance drugs to $5 for a 30 day supply. I was still paying a $10 copay at CVS, so I switched to Target and paid the $5.

Is this still the case since Target sold their pharmacy operations to CVS? I've been curious how much of the "Target charm" remained after that transition.

No idea. I stopped going to Target a long time ago. I know they got rid of the specially designed pill bottles everyone liked and people are annoyed about that.

I've been hit by this too. The scam is really simple:

Take the example in the article: Shire normally sells Adderall for $200. They offer to sell it to UHC for $50. The generic costs UHC $60. UHC takes the generic off the formulary and will only pay for Shire.

For the end user the out-of-pocket cost goes from $10-20 to $50 because brand medications are in the "Premium" category.

By saving $10 UHC sticks you with a $40 higher bill - literally 4x what they are saving.

Targeting this specific behavior is trivially easy: change the law to require insurers to cover generic or brand for any RX at the patient's choice.

Better yet, from the article:

Then, a few years ago, Shire tried a new tactic: giving ever-larger discounts to pharmacy benefit managers and insurers for preferential treatment over the generics. That did not mean lowering the list price of the drug, but rather negotiating rebates that were paid not to the patients but to insurers and middlemen such as CVS Caremark.

Just prosecute them for anti-competitive practice or even collusion. What they are doing is probably already illegal.

Interesting read of comments.

A head of R&D at Advertising Agency decided that he couldn't take any more of the lying and corruption that occurred in the advertising industry. so he went to work in R&D in the Medical Technology Industries Arena.

Six months later he was back as head of R&D at the advertising agency. When asked why he had come back since advertising was so corrupt, he told them that the advertising industry were little children compared to the standard corrupt practises occurring in every area in the medical arena.

He had delight in telling me the reaction of the advertising agency staff at his return.

I skimmed the article, and there is another force at play that benefits insurance companies.

Insurance companies have a federally mandated percentage of revenue that they must use towards the reimbursement of their policy holders' medical costs. In the past, this ratio was too low and they're been slapped with stricter conditions. But Health Insurance is an industry where you can basically pass on your costs to your policy holders with near impunity (the current "healthcare debate" rarely discusses cost control in depth, and instead spends time on the correct level of cost sharing). And if your overall costs grow, then you can raise your overall revenue. And when your overall revenues grow, you have more money to pay your executives.

Consumers lose, everyone else in the healthcare value chain wins.

My sister had an acne breakout in her teen years and went on a brand-name hormone suppliment - it worked wonders. She went on the generic and only had problems - so far as I understand the situation the delivery mechanism is different across brands; though it's very rarely a problem for most people. As always, it's your health at stake - if you feel as though something is not working for you then switch.

Generics mean the active ingredients are the same. Your sister's condition probably reacted to some inactive ingredients.

Generic may work better just as brand name may work better in that case.

Perhaps it's the same as with medical services?

Note that providers won't typically tell you the cost of a procedure unless you give them your insurance.

Don't insurers have negotiated (lower) rates with providers? Also there's typically a relatively large deductible.

I'm guessing that between the negotiated price and the deductible and the non-sense of the insurer choosing something against common sense there's actually money to be made off the patient.

So if you're charged $1000 for an MRI and have to co-pay 200 and the negotiated cost is $200 you actually end up paying 100% of the actual cost. You can redo the math with whatever number, but the point is the percentage you think you're insured for is not real.

If insurer asks you to buy a 10x more expensive drug while they have a much smaller negotiated price, they may end up paying less or actually making money.

My argument for years now has been that "providers" should be required to charge the same price for every patient. In other words, insurance companies should not be able to negotiate prices with them. The idea that an insured person (and his insurance company) is charged less for a procedure than an uninsured person... well that's just wrong.

As usual I like to clarify - providers should be free to set their price for a service/product, but they must charge everyone the same for it. Different providers would be free to charge different prices of course.

American healthcare is weird.

I pay £9.50 for all of my meds. The NHS decides which is the cheapest version of the drug I need. And that's what I get.

It costs £9.50 regardless of the quantity, brand or anything else.

Here in Scotland, I pay nothing to get any prescription dispensed; Wales and Northern Ireland also lack prescription charges. Wales's abolition of charges actually saved money (because they could get rid of the means-testing infrastructure).

Yeah, I lived in Wales for a little while. That was a nice treat.

In Austria the price is 5,85€ for whatever the doctor prescribes (pharmacist is not allowed to substitute a generic).

And if you need lots of meds and you reach some annual threshhold (depending on income), you don’t have to pay anything after that.

Price gouging is the natural consequence of running healthcare on a private, for-profit basis.

Most generic co-pays for medication also are about $10-$12.

'Most' being the operative word. In the UK, the most basic of generic meds are this flat rate as are the latest targeted medications which could cost tens of thousands of pounds if bought with insurance.

Unless it's administered in a hospital, in which case it's free.

The whole US system seems designed to gouge as much money out of the 'consumer' as possible by confusing you. Similar to how we run trains the UK. Except if you miss a train, you won't die.

For most europeans (especially brits), how the US manages to continue to justify the existence of such a system is baffling.

We'd have to compare medication to determine whether that "most" is 51% or 99%.

I'm not saying it's better or worse, don't get me wrong.

Is there data out there that extrapolates Single-Payer tax revenue to relate to insurance premiums? We need that to really compare the overall costs.

I'd be interested in seeing that, because some days I'm all for adopting an "everyone gets it" mentality, especially if the costs are comparable. If I didn't have to deal with miscellaneous billing after the insurance pays them would negate the need for my mailbox.

However, as brought up in another comment of mine, I'd still like to be able to see someone same-day for something (employers too), even if it's non-life-threatening.

You're right, unfortunately I don't have that data. I can only give you my personal experience of the NHS.

The often portrayed boogieman of NHS waiting lists are usually incorrect. I saw my GP this morning after ringing up 20 minutes previously and had an appointment within the hour. I was in and out within 30 minutes with a prescription that was electronically sent to my pharmacist who had filled it before I arrived later today. The whole process cost me nothing, except for the prescription fee which is capped at £120 a year for the heaviest users.

Last week my wife ended up in A&E (what you call the ER). She was seen within 2 hours by a doctor who assessed her, triaged her, gave her some medications (which were free as they were in hospital) and sent her on her way. It's an insanely efficient system.

Primary care in the NHS (GPs, Emergency care) is usually pretty impressive despite what many tabloid papers say.

Secondary care can often have waiting lists but their length is legally enforced with the state having to pick up the tab for private care if wait times are longer than the legal maximum.

America seems to think this is the way to kill your population. It's really pretty great!

Everywhere you look there's just numbers supporting the cost of the whole system. If they were able to break that down into what a typical family pays, and compare; I'd bet you'd get even more people (gasp! Even conservatives, hell I'm almost on board myself) converted to the idea overnight.

The mile high view of USA health care is if we can "eliminate" the poor, the old, the sick, in the long run, it will make our economy stronger. It seems to be doing it's thing.

The life expectancy is coming down for the first time in decades and the stock market is at a record high. It's a "social darwinism" thing. We're a living lab to test the theory out.

That's the mile high view. I'm not sure what the long term consequences are.

> US life expectancy drops for first time in 22 years


And then you all die from an infected telephone booth because all the phone sanitizers have died out.

Joke aside, you still need people in what are now shitty low-paying jobs for a functioning society. So if you're not going to pay the janitor enough for a middle-class life, either make a robot to do his job, or die of dysentery. Do you think USA will be able to make enough robots fast enough to realise that? And will USA society be able to tolerate everyone being upper-middle-class?

My first software job out of college was working for a healthcare company. I worked in the Drug Comparison team (which consisted of 3 people) finding people ways to save on prescriptions by beating the system using software! Yay, helping the world and stuff.

Actually, we ended up selling out and building systems that benefited healthcare provider's formulary plans. For example, not recommending generics, which was most of what we got paid 500k+ per contract to do.

We did do some amazing work on Medicare Part D stuff, tho. We saved some elderly people tons of money by algorithmically reccomending them the right drugs at cheaper cost.

Some of this insanity is covered nicely in the econlog podcast[1] on the book Drug Wars[2]. The NY Times always wants to throw all of the blame at insurers, but they are trying to save money. The generic system is a Kafakaesque set of regulations and processes.

[1] http://www.econtalk.org/archives/2017/06/robin_feldman_o.htm...

[2] https://www.amazon.com/Drug-Wars-Pharma-Raises-Generics-eboo...

I wouldn't be surprised if this was due to issues with some generics not being the equivalent. Concerta is a weird drug with the one generic actually being rebranded brand name. The other generics are not considered equivalent by the FDA but the last time I checked some pharmacy such as Walgreens carry the non equivalents. Apparently they are tied up in a court case.


So I work in advertising specifically focused on pharmaceutical brands. One of my client drugs has a problem where Pharmacists are dispensing as generic where their drug has a different Mechanism of Action and is only prescribed after the generic fails. Pharmacists can actually be incentivized in some cases to give the generic when the brand-name is written. Apparently they don't even have to tell you that they're switching it.

We have multiple clients who are undertaking 'dispense as written' campaigns with healthcare professionals to offset that.

I'm certainly not saying that it is ALWAYS the case that a drug which vs. generic is the best choice. Sometimes they are literally the exact same molecule.

Sometimes though, you're not getting the same level of care. Sometimes not even the same mechanism of action.

I imagine an insurance company's position on that might be the offsetting of liability. If a pharmacist dispenses a generic when the brand-name is different and the treatment fails the insurance company bears the cost of that in the form of extended care. (and possibly other things)

If it has a different mechanism of action it is a different drug. It sounds like your campaign is just more marketing by the pharmaceutical industry which is illegal in most countries.

That's right. It is actually pretty shocking (to me personally) that there are Pharmacists in the USA who are able to legally give DRUG-B when the prescription written is DRUG-A and they are different molecules, different MOA and they Pharmacists are incentivized to do that.

It is a different molecule. It has a different Mechanism of Action and the pharmacists STILL legally deliver a biosimilar version of a different drug and not only is it legal, they are rewarded for it.

I'm a programmer and in the strategy meeting where I first learned that I asked about three times if that was true. I was stunned and mildly infuriated - but all the other people in the room were just sort of tight-lip wide eyed nodding at me. "yes that is actually what happens"

It's part of the reason why we're focusing on DAW campaigns for so many brands right now. Pharmacies are a "wild west"

Now this is a difference between "Generic" and "Biosimilar" - which I may have used an inaccurate term in my previous post.

> Unlike generic medicines in which the active ingredients are identical to the reference small–molecule drug, biosimilars will not be identical to the reference biologics. ... A generic drug, by legal definition, is an exact copy of its reference medicine and must have the same chemical structure.

Generics must be the exact same molecule.

I definitely know we have numerous common cases of our client's drug being written as BRANDED-DRUG-A and the generic version of BRANDED-DRUG-B is given. Our client owns both A & B.

It's shocking. In the USA it is somehow legal.

I monitor my blood pressure pretty closely, and noticed when my blood pressure medication changed between generic manufacturers, one particular manufacturer was less effective, and my pressure went up 10-15%.

I just don't understand medical care in the USA. Medical treatment seems enormously expensive, if you are not insured and you get ill, you die and yet getting insurance seems to be resisted (Obama-care).

Would someone be able to explain (or point to an existing layman's explanation) how medical care works in the USA, the issues with insurance and strengths and weaknesses.

The US healthcare system is deeply burdened with the flow of money between all parties involved in it. Money is integral to the system like the blood in our veins. Without blood pumping (money flowing), the system as it exists today dies.

How Americans obtain health insurance is largely dependent on their age/occupation (retired, coverage thru employer, etc) and income/assets. There is strong incentive to be insured to avoid a yearly tax penalty. People with low income qualify for partial or full subsidy of their insurance cost, largely footed by more fortunate tax- and insurance-paying Americans. But unless they are poor, they are still expected to pay for services rendered out of their deductible, a fixed ceiling in USD that they agreed upon with their insurer (a higher deductible tends to lower insurance cost). Having insurance also significantly reduces the "retail" cost of services and medicine (an uninsured billionaire may happily pay $250,000 cash for an ER visit, while an insured student may struggle to pay their $2,500 deductible for the same thing). One upside to Obamacare is that it has taken a lot of stress away from people, as they historically could have become destitute from massive healthcare bills that overran obscenely high deductibles (now capped under Obamacare). Pre-Obamacare, insurers had a deductible of their own sort, one which allowed them to deem an overrun so high, or a health condition so dire, that they could cut a person off (sort of like a bandwidth cap, but for human life, a lifewidth cap if you will). One (primarily financial) downside to Obamacare is that insurance costs have increased to pay into the subsidy and sky-high bill bucket (and the leftovers into for-profit insurance companies' pockets). So Obamacare, i.e. American healthcare today, is largely an effort to not only insure every American, but also protect them from financial ruin in a health crisis. And to accomplish that, the money must be flowing.

We certainly have a lot of amazing selfless people doing their best to heal the sick, but as the players in this article, people like Shkreli, and some of our congress members make so clear, follow the money trail to its darkest depths and you will find the true face of American healthcare. It's being stymied at every turn and will continue to be until it's either rescued by reform or decimated by profiteers.

This barely touches on your questions and leaves out some critical details but I hope it's of some use.

Thanks for this insight. It certainly does not paint a pretty picture.

It's just that drug makers cut deals with insurance companies. Drop competing generics from your formulary, and we'll give you a good price for our brands. Or maybe on a basket of products. So you get more money, both by paying less for the drugs, and by charging patients more.

Yet another problem that can be solved by a single payer system that can negotiate reasonable prices and doesn't need to profit off its members suffering and death. Get rid of the insurance companies and you get rid of this problem and a whole lot more.

Such a simplistic view. Cancer death rates in the UK are 255 per 100,000; in the U.S. they are about 163 per 100,000.

It’s not so black and white that “single payer is better.”

Health care is always going by to be a scarce resource and it follows the laws of economics just like anything else. It isn’t immune to reality just because it’s important.

> Cancer death rates in the UK are 255 per 100,000

No they're not. Cancer mortality rates (per 100,000) are:

UK: 109.97, USA: 105.78, Spain: 98.06, Australia: 96.36

> It’s not so black and white that “single payer is better.”

In the vast majority of measures, it clearly is.

( Stats from: http://www.cancerresearchuk.org/health-professional/cancer-s... )

This is a straightforward consequence of Obamacare that was predicted before the law even passed. The imposition of onerous cost ratio requirements means a company can make more money only by raising costs, not eliminating them.

I think Obama himself recognized that the Pharma lobby is one of the hardest to beat, and decided to try and sidestep them in trying to improve access to healthcare. Clinton tried and failed due to the Pharma lobby, Bush passed Medicare Part D but wasn't able to give CMS price negotiation power. It's really quite unfortunate for healthcare consumers.

This article left me confused about why this practice exists. It seems like it could only be because the insurance companies are getting some kind of kickback (maybe in the form of lower prices on drugs) in exchange for having these anti-generic rules, but I would think that would be illegal. Can someone who understands explain more clearly the situation?

The article is for lower upper class / upper middle class readers where obviously what the dr writes is what is done aside from questions about "why is money being wasted?". The actual strategy is for making money at the cost of poorer people.

Lets say the name brand is $75, generic is $50. If a poor person gets the generic the insurance company is out $50, well, depending on deductible, etc. If the bureaucracy can be mysteriously blamed for not allowing the generic, at least some percentage of the poor people cannot afford the medication at $75 therefore the insurance company is NOT out $50.

Its merely price based rationing. If you increase the cost of health care, some fraction of the population will be frozen out of the market, just like real estate or car prices or tuition. One of many failures of our current economic system is maximal profit does not coincide with maximal participation rate, some percentage will be frozen out for financial reasons, ranging from not too many like health care, up to most of the population WRT real estate in bubble areas. Eventually once a large enough percentage of the population is alienated and disenfranchised from the system, there will be enough support to burn it all down, until then its the existing slow boil.

Your argument doesn't make any sense. If the insurance company is paying for the drug then they would rather pay $50 than $75 for it. If the person has a deductible, it is conceivable that they would forgo treatment if the price is $75 but not if it is $50 because they didn't think they would use up their deductible, but then they ended up using it up anyway. The insurance company would then save money. But this doesn't seem like it would happen often enough to make this a good bet for the insurance company.

> Then, a few years ago, Shire tried a new tactic: giving ever-larger discounts to pharmacy benefit managers and insurers for preferential treatment over the generics. That did not mean lowering the list price of the drug, but rather negotiating rebates that were paid not to the patients but to insurers and middlemen such as CVS Caremark.

Thanks, I did read this (and thought that it should have been put much earlier in the article and expanded on). But what was left a little unclear to me is whether the deductible calculation was based on the list price. I guess it is, but that does seem pretty dubious. I guess one of the advantages of a single-payer system is that it is a single-price system; I wonder if we don't have the political will for a single-payer system if there is any chance we could at least get a single-price system (or, failing that, at least a system where people who have insurance don't pay more for stuff out of their deductibles than their insurers will pay after they exhaust their deductibles).

I think that the insurance plans I've had have had a flat price for generic and name-brand drugs or at least a cap for each category. So yeah, this is a win for insurers and manufacturers, at the patient's expense.

Same thing for me. When I get refills I see whichever psych happens to be free that day and they always comment on how weird it is that my insurance requires the brand name. I always tell them that I assume the insurance company has cut a deal with Shire and it appears I was right.

But my copay for the name brand is only $20 so it never occurred to me to complain.

The insurers often have PBM contracts that incentivize them in filling specific drugs. This is the most likely reason https://en.wikipedia.org/wiki/Pharmacy_benefit_management

Aren't pharmacies allowed to suggest generic replacement to the drug on the recipe (unless the prescribing doctor explicitly stated to not allow it?)

Do doctors prescribe the specific brand drug and prevent changing it to generics, because the insurer tells them to? That sounds like a solvable problem: doctors that prevent swapping for generics must have valid medical reasons, not only economical reasons. Makes sense?

I have to take levothyroxine and my endocrinologist insists that I take a particular name brand. The amounts are in micrograms and the dosage varies across brands, and since various pharmacies use different generics, the only way to get consistency is through sticking with a particular brand.

I am sure others have had the issue where you shop around for free versions of prescriptions only to have the insurer tell you to sign up for 90 day supply with a cost. They seem rather insistent on it but there have been no repercussions for my ignoring them

I'm relatively new in Germany. As far as I can remember, the doctors always prescribe the generic drug, but I can't verify because I never keep the prescriptions. Can someone confirm?

Does not really matter a lot what the doctor exactly writes on your prescription, because "aut idem" will not be ticked on the prescription in most cases.

The pharmacy then does most of the work and checks with your insurance which drug manufacturer has a contract with the insurer and hands you the cheapest one. This usually is a generic and you would get that even if the doctor wrote the brand-name one on your prescription.

The doctor can decide to tick "aut idem" and you would get exactly the medication by that exact manufacturer prescribed, but you might have to pay extra at the pharmacy for this so this is really uncommon.

What's the guarantee that branded drugs won't have any side-effects. There's none. and they're pretty expensive too.

People will anyway.

You only needs the slightest derivation from one's habit and it's over.

Adderall XR and Metformin actually are better than the generic.

Metformin is the generic. Glucophage is its equivalent brand.

I get a 30 day (1.5 grams twice per day) supply of Metformin at Walgreens for < $5.

OT, but how did the brand name Glucophage get approved? I don't see how calling a drug "glucose eater" is anything but misleading.

In general, stimulants were once more popular as apatite curbing agents. When the drug was developed, they probably thought people would use it to lose weight, so 'glucose eater' has the same general effect they were going for: weight loss.

Even having health insurance is not enough to afford healthcare in America these days. The fragmentation of American Healthcare in to this S##tshow, whos only function is to gouge the consumer, is proof that the US needs single payer, like the rest of the world.

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