Upping Generic CV Drug Scripts Could Save Medicare and Patients Millions

Changing the prescribing behaviors of physicians in the United States with regard to CV drugs alone could save Medicare more than $600 million a year, an analysis shows.

“Despite focus on this issue for a while, there remains large potential savings from increases in the use of generics over brand-name drugs when substitutes are available,” senior author Alexander T. Sandhu, MD (Stanford University School of Medicine, CA), told TCTMD. The results of his analysis suggest that much of the potential savings that could come from switching to generics is centered around a minority of clinicians who write 10 or fewer prescriptions per year for a given brand-name drug.

“That might illustrate that some amount of what we found is related to unfamiliarity with the availability of a generic for that specific drug,” Sandhu added. “This is where systems level interventions can be incredibly powerful.”

One example of such an intervention is for a healthcare system to change the default in the electronic health record to always prescribe the generic when there is an equivalent available. At least one study found that doing that significantly increased the generic prescribing rate, he noted. Laws about mandatory generic substitution by pharmacists is another example of system-level interventions. Currently, 20 states require generic substitution by pharmacists if the prescriber did not specify “dispense as written,” and 30 others allow, but do not require, pharmacists to substitute generic equivalents for brand-name drugs. Sandhu and colleagues found that $11 billion of the $23 billion in CV prescriptions written for Medicare Part D patients in 2017 went to prescriptions that had a generic equivalent.

The study, published online December 9, 2021, ahead of print in Circulation: Cardiovascular Quality and Outcomes, and led by Iris Ma, MD (California Pacific Medical Center, San Francisco), was a cross-sectional analysis of fill and cost data in the 2017 Medicare Part D Drug Public Use File, which contains information on brand-name and generic spending nationally, by state, and by individual clinicians. The researchers identified at least one generic substitute for 122 brand-name CV drugs, including antiarrhythmics, anticoagulants, antihypertensives, antiplatelets, diuretics, and lipid-lowering agents.

Among 856 million monthly prescription fills that had an available generic substitute, only 2.4% were filled with the brand-name drug. Nevertheless, these prescriptions accounted for 21% of the total Medicare Part D prescription spending in 2017. Ma and colleagues estimated that after adjustment for brand-name rebates, appropriate substitution of the brand-name drugs for generic equivalents could have saved Medicare Part D $641 million, including $135 million that came out of patients’ pockets at the pharmacy.

The greatest potential savings were found to be for lipid-lowering therapies. Generic prescribing of ezetimibe and rosuvastatin, for example, would have saved Medicare $78 million a year. The generic equivalents of the brand-name counterparts for both drugs have been on the market since 2016.

Prescriptions, Priorities, and Preferences

Of 418,836 clinicians who wrote 11 or more prescriptions per year for a CV drug with a generic option, the generic was dispensed approximately 72% of the time. On the other hand, among those who wrote 10 or fewer total prescriptions per year for a CV drug with a generic option, the filled drug was more likely to be the brand-name. The researchers calculated that 50% of the projected savings for Medicare Part D could come from substituting generics in this group alone. By specialty, cardiologists prescribed the most brand-name CV drugs, but the potential savings with generic substitutes was estimated to be similar in comparison with internal medicine and internal medicine subspecialties.

Improving healthcare spending is not [about] finding one clear fix for everything: it's finding lots of these little things that we can do to improve our efficiency. Alexander T. Sandhu

Sandhu said although their research did indicate an uptick in the generic prescribing of ezetimibe and rosuvastatin in 2017 and 2018, the fact that the drugs have only recently transitioned to generic status may explain some of the continued brand-name prescribing seen in the study.

“Maybe the patient had a year's worth of Crestor prescribed and was continuing to get Crestor,” he observed. “There is also a possibility that a patient needed a refill and their clinician wasn't aware that generic rosuvastatin was available and refilled Crestor instead.” Nevertheless, he said, decreasing spending through generic substitution is relatively simple and should be higher priority for clinicians and healthcare systems.

“I think one of the takeaways is that improving healthcare spending is not [about] finding one clear fix for everything: it's finding lots of these little things that we can do to improve our efficiency,” Sandhu said. He added that while the analysis likely overestimates some of the potential savings, it highlights the fact that a small number of physicians are not on the same page as their peers.

Lastly, Sandhu said the patient’s viewpoint should be factored into prescribing practices, especially if they have very strong preferences for a brand-name drug that they've been on for a long time.

“While that preference should be respected, those patients should be educated by their physician about how that [option] could be affecting their out-of-pocket costs, and about the substantial data that we have regarding comparable effectiveness and safety of generics,” he added.