(The Air Tran challenge: they offer Wifi on my flight, so how well can I use it?  Post 1.)


In 2006 I offered you the Top 25 psychiatric prescriptions.

Want to see what's changed in 2009?

The decade long WMD that was Depakote?   Does anyone want to apologize for that?  Hello?

II.

You have to dig a little bit.  Look at Wellbutrin XL, at 2M, down by 73% from 11M.  But bupropion (generic Wellbutrin) is up, at 8M.  Add the two together, and you're back to 11M.  This doesn't even account for generic bupropion SR + Wellbutrin SR.  So in this case, the company isn't marketing the branded drug, but doctors still want to use the chemical.

This makes it hard to argue that it's Pharma that is pushing the "overprescription" of Wellbutrin (in contrast to Prozac, which has fallen.)

Meanwhile, Risperdal is up-- but it's generic now.  So why up?  Because many insurance plans ask for it first.  Same with Celexa, which is the "generic" of Lexapro (I know, I know).  Add the two together, not much change.

But what is evident here are three trends:

• SSRI/SNRIs are on the way out, except for Cymbalta.
  
• antipsychotics are up, probably taking over for antidepressants
• antiepileptics appear to have been a terrible, embarrassing fad.
  
• either more people are on medications than in the past, or the same number of people are getting more medications.

III.

In 2008, drugs sales rose only 1.8%. in 2009, by 5%.  Those are both low.  Very low.

Yet:

• number of generics exploded to 75% of prescriptions in 2009, up from 57% in 2004
• number of branded drugs fell by 8%
  
• total drug sales climbed to $300B (more spending on drugs).
• But generics only accounted for $75B. 

In other words, even though we are using way more generics, we are either: using more medications than ever before (as above); or the few branded ones we are using are even more expensive than ever.

That turns out to be the case:  specialty drugs (e.g. Avastin) for chronic illnesses jumped to  21% of the sales. 

If you couple post-Obama American medicine's (and I'm not blaming him) focus on preventative medicine and long term maintenance-- where Big Clinics and Big Insurance will be the winners; with Big Pharma's move away from expensive acute treatments to really expensive long term treatments, you almost have to wonder if that's more than a coincidence?



III.

Here's the punchline: there's a little over $100B in waste (pdf) due to outright noncompliance, according to Express Scripts.  This number is undoubtedly high, because it is based on monthly refills-- for example, if it takes you 40 days to use up a 30 tablet supply, then you'll use only 9 scripts a year.  Based on this, they estimate a compliance with antidepressants of 83% (i.e. 10 scripts a year).  However, psychiatrists (unlike most other specialties) ask you to come back every month or two months at which point you'll get a new script-  regardless of how many you actually have left.  No one says to their psychiatrist, "you know, I still have a lot of Cymbalta left over from the last script."  So the actual noncompliance is likely much higher.

In other words, while prescriptions may cost a lot, the real budget killer is waste, thrown in garbage cans or flushed down toilets.

IV.

And I'll say what no one dares say: how many times does a patient agree to "take" Zyprexa and Effexor just to get the Klonopin?   Or Lipitor and glucophage, just to get Percocet?  True story: there's a pharmacy I walk by on the way to the sketchy city movie theatre, and every time I pass it I see guys tossing full pill bottles into the outside trash can.   

V. 

The solution: have Pharma pay for the first 30 days of any treatment (e.g. vouchers.)  Only after a patient has been on it for at least a month should the insurance cover the rest; this cuts out the wasted one or two or three first attempts at medications ("I didn't like the Cymbalta, so I stopped it.")

Copays, hated by all, are a necessity: free medications are not valued by patients/humans; nor should the copay be subsidized by medicaid or other plans.  Five dollars is enough.

And, finally, the most hated of all (choose a or b):

a) all prescriptions should require a prior authorization by the doctor, and a supplemental one every six months.  The easier it is for docs to prescribe, the more they will prescribe.  Now you'll think twice before you add on the Buspar.

b) you make all medications full access, and priced however Pharma wants, but you give each doctor a pharmacy budget, e.g. $20/patient per month. 

Another reality no one wants to hear: doctors will have to accept managed care at the treatment level (e.g. formularies) or they will have to accept managed care at their reimbursement level.  Or both.

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