EP344: The High Cost of Generic Drugs, With Steven Quimby, MD

I was on LinkedIn, and someone was saying, “Oh, there’s no real money in generic drugs. It’s not a huge issue if patients are paying 10 bucks instead of 93 cents for something. It’s not like anyone is getting rich off of that, and it’s not like patient impact here is super meaningful.” This is a pretty common refrain, actually; and from a conventional wisdom perspective, I get it, especially for those living comfortable middle- or upper-middle-class lives where an extra $9.07 for a prescription isn’t a huge deal—except there are big-time issues with the generic supply chain that are worth billions and billions of dollars and that have a major impact on patient health. So, let’s discuss.

I started casting my eye over to what was going on on the generic drug front mainly because of the huge lawsuits in the news lately that were either filed and/or settled. Generic drug manufacturers are and have been the defendants in these lawsuits, accused of price collusion amongst other things. These lawsuits aren’t fighting over chump change either, unless you consider hundreds and hundreds of millions of dollars as chump change, that is.

The number of zeros on the table in these lawsuits may strike you, as they did me, as a factor of interest. I mean, we’re talking about generic drugs here. The cost of goods on these drugs—there was a WHO study on this—and the cost of goods to manufacture a small molecule generic is, a lot of times, pennies. Further, there’s no innovation undertaken by generic manufacturers in their manufacture of generic meds.

Just so no one gets confused here, the rationale branded pharma manufacturers tout for high-cost branded (ie, new) drugs is that branded pharma manufacturers have to spot the R&D (research and development) dollars to come up with the new therapies and they take a lot of risk therein. Generic manufacturers, on the other hand, are getting a recipe that has been handed down to them. There is no R&D. There is no innovation.

So, to restate the situation analysis, we have generic manufacturers spending no money on innovation and enjoying, many times, a low cost of goods. If the price were set using a cost plus methodology, you’d expect the prices paid by payers and patients to be correspondingly low—except they aren’t.

Depending on what study you look at, somewhere between 29% and 44% of patients who have been prescribed a med say they aren’t taking it because it is unaffordable. Considering that 90% of the prescriptions written in this country are for generics, one could logically assume that there’s some generics in that mix that are unaffordable due to their high prices.  

But there’s a compounding factor here: The patient affordability problem has another aspect to it beyond just patients having to pay a portion, or all, of the price of generic meds that may be, let’s just say, higher than one might expect them to be given the cost of goods. But here’s this other factor: The share of patient out of pocket is weirdly high when it comes to generics. Consider that generics and branded generics account for 19% of invoice-level spending but represent 65% of patient out-of-pocket costs (IQVIA National Prescription Audit, 12/2020). So, that seems out of whack.

But keep in mind, as I mentioned earlier, that 90% of prescriptions written in this country are for generics. That’s five billion scripts a year. As my guest in this healthcare podcast, Steven Quimby, MD, says, generic medications touch many more lives than new branded drugs.

Obviously, GoodRx comes up in the conversation in this episode. If you want to learn more about pharmacy list prices and how GoodRx makes money, listen to the conversation I had with Ge Bai (EP306 and AEE13). Several people actually mentioned on LinkedIn and Twitter that hers was one of the best explanations they had heard on these topics, so I recommend those shows. 

The show also with Vinay Patel dives pretty deeply into the “what’s the what” between PBMs and pharmacies (EP241) if you’re looking for more on that.  

Dr. Quimby also mentions how important it could be for providers to know at the point of prescribing what the cost of medications are for a patient and get this information right in their EHR system. Refer to the episode with Carm Huntress (EP284) for more info on that. 

My guest, as I said, Steven Quimby, MD, is an author and newly retired physician. His father was a pharmacist with a little drugstore that thrived in the late 1960s and early 1970s, so he literally grew up in the business. Dr. Quimby recently wrote a book called Billions in Your Generic Drugs. In sum, it’s a supply chain where not only is nobody watching the henhouse, but everybody within that supply chain has a very, very vested interest to see prices go up. This is kind of a theme in healthcare, but nonetheless.

Oh, and one last point to ponder before we get started here: Dr. Quimby mentions at one point that 86% of Americans believe that their health insurance plan always offers the lowest price for a generic and 67% (two-thirds) of people in this country have never heard of GoodRx or other shopping tools. So, yeah … really makes you realize you live in a bubble.

You can learn more by reading Dr. Quimby’s book Billions in Your Generic Drugs.  

You can also reach Dr. Quimby on Twitter and LinkedIn. 

Steven Quimby, MD, is a physician who has worked in academic medicine at the Mayo Clinic and in private practice. He has been involved in drug treatment studies, including major pharmaceutical trials, and maintained an active interest in the interface of corporate business, pharmacy, and medicine for over 50 years.

Dr. Quimby is concerned escalating prices for generic drugs, which fill 90% of our prescriptions, threaten access to needed medications and patients going without treatment risk worsening of their medical conditions and further costs. Too often controversies over high new drug prices and the funding of new drug development and innovation obscure addressable problems in the generic drug supply and financing chain.

05:54 What are the current lawsuits involved in the generic drug space right now?
06:52 How is price fixing happening in the generic drug space?
07:58 “If I was the major payer for drugs … I’d want to know answers.”
08:06 What’s the scale on new and generic drugs?
09:02 What’s the problem with using price tools for generic drugs?
10:22 “I think right now, virtually everyone should be checking [those sites vs] their insurance price.”
10:47 Are payers paying too much for generic drugs?
11:53 Who are these generic manufacturers?
12:10 “They’re distinctly different corporations than those that we have called Big Pharma.”
13:55 Why is it important to have adequate numbers of manufacturers for generic drugs?
17:03 “We just can’t get legitimate acquisition and then sale prices of the actual drugs.”
17:17 “The industry’s opaque to all of these things.”
19:39 “The prices that patients are getting at the prescription counter are so high that some studies say a third of them or more are walking away without buying the drug.”
20:02 AEE13 with Ge Bai, PhD, CPA, on the GoodRx model.
20:50 EP241 with Vinay Patel.
22:05 What and who should be on formulary?
26:24 “If they’d give us the numbers, we could see when it happens.”
28:58 How can we overcome the challenges of these high generic drug costs?
30:38 EP284 with Carm Huntress.
30:46 EP334 with Sunita Desai, PhD.  
31:26 “How can we judge value when we don’t know price?”

You can learn more by reading Dr. Quimby’s book Billions in Your Generic Drugs.  

You can also reach Dr. Quimby on Twitter and LinkedIn.