Lately we've been thinking a lot about drugs. According to a study released by NCCI last year, prescriptions are taking an increasing portion of medical care in workers compensation: rising from about 6.7% of total costs in 1997 to 12.1% in 2002. The precentage today is probably higher than that.
So what? Is this really news? The LynchRyan focus is not so much on rising costs as on which costs are rising: in other words, which drugs are being prescribed under the workers compensation system and why.
Generic versus Brand Name
In the battle between generics and brand name drugs, brand names are winning out big time in workers comp. The NCCI study (going only through 2002) reveals that generics are prescribed 79% of the time. This sounds good -- where generic equivalents are available, they are prescribed a majority of the time. But let's look a little deeper. The study reveals that 56% of the time, there are no generic equivalents. In other words, over half the time doctors are prescribing brand name drugs, which are always more expensive. As a result, generic drugs comprise only 35% of written prescriptions. Beyond that, doctors are making some interesting choices in which drugs they prescribe. Take a look at NCCI's top 10 drugs by total paid:
First in line, Celebrex, an anti-inflammatory with no generic equivalent. It's advertised as an arthritis drug.
Second, Oxycontin, a painkiller originally developed for terminal cancer patients. (Some studies show still show Oxycontin as the #1 drug under workers comp.) Oxycontin's addictive potential and readily abusable state are well documented.
Third, Vioxx, another anti-inflammatory (recently removed from the market).
Fourth, Hydrocodone, another painkiller, and the first generic to make the list.
Fifth, Neurontin, prescribed for pain. This drug is specified for certain seizure disorders and for the pain of shingles. Why is it so popular for workers comp pain?
The top 10 list is rounded out by Ultram (a painkiller with a generic available); Carisprodol, a generic muscle relaxer; Cyclobenzaprine, another generic muscle relaxant; Soma, a brand name muscle relaxant; and Ambien, a brand name sedative.
I am tempted to ask, what's the problem with Soma's sales force? Why is their brand lagging behind the generic equivalents?
In general, pain killers comprise 55% of workers comp prescriptions. No surprise, given that pain is a major component in injuries. But why are doctors relying on brand names, when there are very powerful generic drugs available for pain? Why prescribe Oxycontin? Why is Neurontin so popular?
Is this what consumers want?
There is one major difference between prescriptions written for workers comp and those written under conventional health plans. When you fill a prescription under your health plan, you almost always are asked for a co-payment. The co-pay tends to be much higher for brand name drugs, which is an incentive for the consumer to choose a generic equivalent. But in workers comp, there is never a co-pay. Thus there is no incentive for the consumer to make do with a generic equivalent. Does this mean that consumers -- injured workers -- are driving up the costs of prescriptions by requesting brand name medications? It might be a factor, but I doubt that it's a major factor. The answers lie in the highly trained minds of the doctors. Just what are they thinking? What leads a doctor to prescribe a powerful and addictive drug, when a safer generic is readily available? What is the specific decision making process for a doctor when he or she takes out the little prescription pad?
This is a workers comp blog. We don't presume to have the answers to these compelling questions. We do try, however, to identify the key issues and this is indeed a big one. Prescription choices and costs are an important dimension of the workers comp world. The continuing popularity of the widely abused Oxycontin, the off-label use of branded drugs such as Neurontin, and the heavy reliance on branded anti-inflammatory drugs add up to big profits for the drug companies. But are they medically necessary? Are these drugs really what injured workers need to get better? Are doctors making the right choices for the right reasons? Only time -- and better data -- will tell. We will surely revisit this issue in future blogs.