Some insurers insist that patients forgo generics and buy brand-name drugs
nytimes.com
nytimes.com
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.
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.
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.
“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...)
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?
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.
The fact that they wouldn't dispense an alternative when asked until having the doctor update the Rx kind of supports this as well.
The only thing that might be different, as far as I can tell, is the adhesive they use for the sticky part.
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.
This is, obviously, quite irritating, not to mention expensive.
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.
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.
A medication I took last year cost around $90-$100 or so. The insurance covered all but $10 of that.
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.
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...
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.
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.
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.
Can you rephrase this? I can't grok what you mean.
http://cmlnetwork.ca/generic-imatinib-is-it-really-the-same/
http://cml-iq.com/generic-gleevec-is-the-same-the-same/
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.
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.
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.
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.
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".
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).
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.
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?
https://www.nytimes.com/2015/06/17/business/generic-ritalin-...
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.
But, it seems likely that this effect could lead them to sometimes perform better as well.
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.
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.
Here’s one study addressing that specific issue:
For people taking drugs with a narrow therapeutic index, though, that variation is huge.
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.
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 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...
Sooner or later you are going to wake up and realise that a government-run single payer scheme is the only way to go.
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.
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.
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.
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.
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.
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.
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.
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.
> 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.
...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.
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.
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.
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)
Its an eye opener.
I'm sure there could always be complications but there are supposed to be laws in place to stop hospitals from price gouging.
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.
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.
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.
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.
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.
I stopped after reading this.
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.
https://www.goodrx.com/how-goodrx-works
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).
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.
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.
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.
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.
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.
Generic may work better just as brand name may work better in that case.
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.
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.
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.
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.
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.
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!
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.
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
http://www.cnn.com/2016/12/08/health/us-life-expectancy-down...
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?
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.
[1] http://www.econtalk.org/archives/2017/06/robin_feldman_o.htm...
[2] https://www.amazon.com/Drug-Wars-Pharma-Raises-Generics-eboo...
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)
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.
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.
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.
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.
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... )
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.
But my copay for the name brand is only $20 so it never occurred to me to complain.
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?
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.
You only needs the slightest derivation from one's habit and it's over.