Q: Is brand medically necessary?
"If people knew how much time we spent on stuff like this, it would blow their minds."
This conversation was had between me and a fellow child psychiatrist. Here's the back story: Intuniv is a medication commonly used in the treatment for ADHD. It's a long-acting form of a medicine called guanfacine that costs four bucks at most pharmacies. The good folks at Shire pharmaceutical company worked out some great deals for Texas Medicaid and earned a place on the Medicaid formulary (a list of prescription drugs covered by insurance).
Fast-forward seven years to today. Both my colleague and I began to get rejections from the pharmacy for Intuniv. This was odd to us because just as recent as December the prescription was covered. When a hardworking clinic nurse finally found the time to call the state, we learned that a generic version of the medicine had become available, and the state operator of Medicaid informed the nurse that handwriting "brand name medically necessary" is required on the script for them to cover the brand name.
Now I hope everyone knows how ludicrous this is.
First of all, most generics (outside of thyroid meds and occasionally Risperdal) are fairly equivalent to the brand name counterparts. So for the insurance – in this case, Medicaid – to insist that the provider write "brand name medically necessary" is disingenuous at best because technically, brand name is not medically necessary. So why did we have to do this?
Because there are so many hands in the cookie jar, Shire and Medicaid have a contract for their medications to be offered at a certain cost. When the generic comes on the scene, they (typically) push the price down through competition. Well since Medicaid doesn't have a contract with the generic drug maker, they will not pay for it, even though (typically) the manufacturer's cost of the generic is less than the brand. To add insult to injury, no one at Texas Medicaid even made an adequate attempt to contact providers in Texas to let them know of the change.
The result: patients can't pick up their medications and providers have to lie.
In the P.S.Y.C.H. system, prescription costs will be leveraged by multiple entities – in this case the states – and costs will come down as a function of the market. This relieves all the other downstream issues because patients will be able to afford their medicines at reasonable prices, providers can go back to writing meds as they are licensed and ethically bound to do, and we place the patient and provider back at the center of the health care paradigm.
I'd say it's a win-win.