Just as no two patients have the same biochemistry, no two medicines are exactly equivalent. But if your primary objective is to reduce short-term costs, that’s an inconvenient truth.

 

Cost-based medicine is based on the concept of “practice variation”—that every patient suffering from the same condition should be treated exactly the same way.

 

But if one medicine is effective for 40 percent of any given patient population, and another drug within the same therapeutic category is also effective for 40 percent of the patient population (and we can’t predict which 40 percent will respond to either treatment), how can an insurance company, or the federal government, decide which drug to reimburse?

 

Increasingly they’re relying on cost-based comparisons. In other words, if two medicines are “equally effective” at 40 percent, they will opt to reimburse the one that costs less. And that’s bad medicine.

 

I am a big believer in FDA-approved generic drugs. They are safe and effective and represent an enormous opportunity for health care savings. I applaud insurance company programs that seek to educate consumers about them. However, I am a bigger opponent of forced switching. Disempowering physicians and patients results in bad outcomes.

 

Consider the Blue Care Network of Michigan (BCN). A program (now discontinued) sent letters out to their participating primary care physicians offering a $100 payment “for each member in their panel with a BCN pharmacy benefit who fills a prescription for a generic lipid lowering agent.” In other words, we’ll pay you $100 for switching your patients to a generic statin.

 

According to a recent ABC investigative report, “Blue Care Network in Michigan paid 2,400 doctors $2 million to switch their patients from Lipitor to a generic version of its competitor, Zocor. They were paid $100 for each patient they switched from Jan. 1 through March 31, 2007.” In other words, we’ll pay you $100 to switch your patient to a generic statin that isn’t even a generic version of what they are currently taking.

 

When asked by the ABC reporter if patients knew their doctors were receiving payments from the insurance company in return for a service that helps to increase the profits of the insurance company, the response from BCN was “not specifically.” In other words, no.

 

“Our prescription claim records indicate you may be taking Lipitor for high cholesterol,” BCN wrote to their customers who were prescribed Lipitor. “Another lipid lowering drug, Simvastatin, works as well as Lipitor but is available as a generic and costs a lot less.”

 

“Not specifically” seems to be more than an evasive answer to a journalist’s question. It appears to also be a creative viewpoint on bioequivalence—a flawed and dangerous one. How will the average consumer read and understand such language? Nowhere in the consumer letter does it mention that doctors will be rewarded for making the switch.

 

Where are the medical guidelines on the best ways to monitor a patient, particularly an already stable one, being switched from one statin to another—specifically from one molecule to another?

 

This isn’t only an American problem—it’s something we’ve learned from our friends over in Europe. An observational study of a large United Kingdom primary care database showed that patients who were switched from established Lipitor therapy to generic simvastatin experienced a 30 percent increase in relative risk of cardiovascular events or death compared to patients who remained on Lipitor therapy.

 

The analysis included 11,520 patients (2,511 patients who had taken Lipitor for six months or more and were switched to simvastatin vs. 9,009 patients who were taking Lipitor for six months or more and then remained on Lipitor therapy).

 

A secondary analysis of the same data showed that patients who were switched from Lipitor to generic simvastatin were more than twice as likely to discontinue their treatment compared to those who remained on Lipitor therapy (20.5 percent versus 7.62 percent). The reasons for discontinuation were not available from the database, though disruption in treatment has been associated with poor adherence in previous studies of statins and other medications.

 

If you want to save money and save lives, the “switching” we need in the United States is a one from a focus on acute care to one on chronic care. American health care is designed to provide acute care, but too often neglects the urgent imperative of chronic conditions. This disconnect will become even more problematic as Baby Boomers continue to age and the fastest growing demographic segment in America is the over-75 population.

 

The argument that healthcare is too expensive is too broad. A better argument is that waiting until Americans become seriously ill to intervene is too expensive.

 

The health care community and the public policy community must work together to develop new cost-efficient programs that account for modern genomics and individual screening because one-size-fits-all treatments—and reimbursement strategies—are dangerously outdated in what must be an era of patient-centric medicine.

 

The repercussions of choosing short-term thinking over long-term results, of short-term cost-based choices over patient-based care, of “me-too” medicines over the right medicine for the right patient at the right time—are pernicious to both the public purse as well as the public health.

 

 

 

The Journal of Life Sciences welcomes commentaries. To submit a piece, contact Daniel S. Levine at daniel.levine@blsmg.com or 415-591-5449.