Generic-Drug Price Fixing: Is It Happening?

It started with an inhaler.

Like many of you, I am a rheuma­tologist. And like you, I see some patients more often their own primary care provider. This is so often the case that I have gradually devolved into their backup, all-purpose doctor. I am the doc they notify when they get hospitalized for pneumonia or if they’re trying to decide whether to go ahead with the hip replacement they were told they need.

From the patient’s perspective, I can understand the confusion. It must be difficult for them to understand why I seem keenly interested in some problems, but not others. After all, because I am the physician ordering the urinalysis, I must be the right doctor to approach about their urinary tract infection or their kidney stones.

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Thus, I found myself trying to figure out why my patient was short of breath. In retrospect, the complaint was not new. In my defense, when a patient meets you because of digital ischemia caused by a medium-vessel vasculitis, his ability to run up a flight of stairs seems a little less interesting. Over the years, however, as his rheumatic disease improved, dyspnea gradually worked its way up his problem list until it was the only issue left.

He knew what the problem was—for years, he was under the care of a pulmonologist for his chronic obstructive pulmonary disease. The diagnosis was well earned, after many years of smoking in a previous era, when smoking was encouraged. Honestly, his condition had not changed much: diminished air exchange, a faint wheeze at the end. I had just never thought of it as my problem to fix.

When he started telling me about scouring the shelves of his local pharmacy for Primatene Mist, an inhaled form of epinephrine that was taken off the market in 2011, I knew I had to step in, at least temporarily. I gave him a prescription for a few inhalers, extracted from him a promise to find a new lung doctor and sent him off. My good deed for the day.

I am not a conspiracist. I don’t believe a dark state is controlling the government. … I’m pretty sure that wasn’t Elvis who was spotted in the Nashville Publix parking lot. That said, I find it difficult to look at the price of generic drugs & not wonder whether the conspiracists may be onto something.

Or so I thought. When he returned for his routine follow-up appointment, I was not surprised to learn that he had not yet seen a pulmonologist—I knew it might take a few tries to make that happen. I was surprised, however, to learn that he had picked up only one of the two inhalers I had prescribed. Generic albuterol was cheap, and he was pleased to inform me that it seemed to be helping. The other inhaler was not generic and not cheap. He learned the prescription would have cost him $100 out of pocket, so he declined to pick up the drug. Perhaps not being able to breathe was not so bad, after all.

Generic Drugs 101

The U.S. Food and Drug Administration (FDA) defines a generic drug as “a medication created to be the same as an already marketed brand-name drug in dosage form, safety, strength, route of administration, quality, performance, characteristics and intended use.”¹ The generic drug does not have to be completely identical to the original drug, but it does have to demonstrate bioequivalence, meaning that a patient should be able to take the brand-name drug one day and its generic counterpart the next and not notice a difference in effect.