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Generic substitutions may be more costly in the long run
 Richard L. Lindstrom |
The issues surrounding the prescription of topical medications to prevent damage to the eye, as in glaucoma, or to treat sight-threatening disease, as in a corneal ulcer or significant intraocular inflammation, are complex. One thing is clear: The physician who is charged with the duty of representing the best interests of each individual patient is losing control of therapy to others, including government regulators, third-party payers, institutional pharmaceutical committees and pharmacists.
It is becoming a common occurrence for patients to be dispensed a medication that may be quite different from what the physician intended. In many cases, in self-limited diseases that represent minimal risk for severe visual loss, little harm is done. But in other cases, the substitution of a generic or similar category product for the one specifically recommended can potentially result in poor therapeutic efficacy and significant risk to the patient.
In cases in which the patient makes an informed decision to accept a generic or similar category product and accepts the risk of suboptimal therapeutic efficacy to save money, this can be considered the exercise of an individual’s right to participate in the decision making surrounding his or her care. However, in most cases, generic or in-class substitutions are made by third parties without informing or obtaining the consent of the patient or surgeon. To me, this seems just plain wrong. The argument that the process is saving the third-party payer money or increasing the profit of the pharmacy seems a weak excuse unless patients, in consultation with their physician, are properly informed and agree to the substitution.
Certainly, we all support the cost-effective practice of medicine, but in the case of sight-threatening diseases such as glaucoma, ocular infection or severe inflammation, the cheapest bottle of drops in the therapeutic category may not be the wisest choice from the patient’s perspective. For me, when conflicts of interest present in the treatment of patients, the patients’ best interests must come first, not the third-party payer’s or pharmacy’s or, for that matter, the manufacturer’s. If a patient knowingly chooses to accept a less expensive method of therapy, I can accept this decision. If others pre-empt patients’ right to their and their physician’s preferred mode of therapy, I am opposed to the process that allows this to happen. Such is increasingly the nature of modern practice. We prescribe one drop, and patients return for a follow-up appointment with another, usually in the same category, in hand. Sometimes they are responding to therapy despite substitution, and other times they are not. Now the physician must try to decide if the therapy or the therapeutic is ineffective.
It is beyond the scope of any physician to develop a clinical comfort zone with the relative efficacy and potential side effects, for example, to the ocular surface, of every discount manufacturer’s generic alternative to every medication they prescribe. Perhaps the future is the cheapest therapy or therapeutic, regardless of safety or efficacy, but it is a future that is a frightening one to the caring and concerned physician, and I would suspect to the patient, if he or she fully understood the consequences.
Unfortunately, there appears no turning back toward physician-patient control in the selection of a preferred therapeutic agent when a third-party payer is involved, as the complex cost-benefit and risk-benefit decisions are being progressively transferred to others. I find this trend disturbing and suspect it will be damaging to some. It may save the system a little money in the short run, but I suspect trusted, reliable, effective therapy, even if slightly more expensive, might actually be cheaper in the long run if acute and progressive vision loss, which is extremely costly to society, is avoided.