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Old Drug, New Brand; Lower Dose, Higher Price

By Dr. Sultan Rahaman
. 2 Comment(s)

A few months ago I was requested to attend a mandatory hospital family medicine departmental meeting. It was held at a top local restaurant, a steakhouse in this case. Not surprisingly the event was sponsored by a pharmaceutical company. This means that the pharmaceutical company paid for all the sirloin steaks and the room to hold the meeting. This was in return for allowing the company to promote a medication to the doctors attending. It was also not unusual that the speaker was a physician from an out of town Ivy League medical institution. He spoke about the wonders of a new drug Silenor , for patients having trouble staying asleep. I was stunned when I realized that this was a new brand for an old tricyclic antidepressant doxepin, which had been around for decades. The FDA approved doxepin in March 1974, 37 years ago. Now in my experience doxepin at a dose of at least 50 to 75 mg at night is required to improve sleep, very infrequently a dose as low as 25 mg nightly works for this purpose. Silenor is available only in 3 mg and 6 mg doses! The retail cost for a month supply is about $150. I find this hard to believe, but let us accept for whatever reason that doxepin 6 mg works better than higher doses for sleep. Why not use the already available slightly higher 10 mg dose of generic doxepin? At this dose of doxepin, a month supply would cost patients only $4 at many pharmacies. I seriously doubt that patients would have side-effects with just the extra 4 mg of doxepin, when it had been used by many patients safely for decades at 150 mg nightly for depression. This reminds me of AstraZeneca’s (an R&D-intensive pharmaceutical company) Prilosec/Nexium strategy.

I am paid about $30 for an average Medicaid follow up office visit, and about twice that for a Medicare patient. Is it possible that I could alter the name and slightly change the method in which I conduct a routine ear examination and bill the average office visit at an outrageous price of $100? Perhaps I could examine only one ear and call it CPSOE (cellular phone specific otoscopic examination).

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  1. Jennifer

    What about when the companies tweak their product a bit after it goes generic? i.e Yaz. They added Folic acid and now they have Beyaz.
  2. Joel Weddington MD

    Your experience with reimbursements is interesting, and the reality is that many physicians do indeed get $100 visit fees from Medicare by manipulating coding and over-diagnosing. Where I come from it's not considered cheating at all - it's called "business as usual," "SOP," and "growing the practice," and most docs don't even take Medicaid, they go to county care. Until a large enough and brave enough group of physicians tackles these exploitative practices, they will remain under the radar.

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