Angry Doctor

Saturday, May 27, 2006

Conspiracy Theory

Yes. Another ST Forum letter to make angry doc angry. And on a weekend too!

May 27, 2006
Some patients have no choice but to buy cheaper medicines across the Causeway

I appreciate the advice to be aware of the risks of taking counterfeit medicines from Jason Humphries, President of the Singapore Association of Pharmaceutical Industries, 'Beware, fake drugs can cause serious problems', and Dr Raymond Chua, Honorary Secretary of the Singapore Medical Association, 'Buy drugs only from well-known pharmacies' (ST Forum, May 20).

But I understand that those who seek cheaper medicines across the Causeway want to stretch their dollar.

There are three reasons why Singaporeans buy medicines from Malaysia or overseas. These patients have no choice in their own country.

Firstly, the prices of branded drugs are tightly controlled by the manufacturers or importers, with high profit margins, because patients are denied the free choice to purchase the equivalent or good generics from open competitive markets like in the US or Europe.

Doctors in Singapore only prescribe branded medicines to be safe and comfortable. The pharmacists here only follow rules and keep records to sell the prescribed drugs as stated by the doctors and charge you the same prices as instructed.

So does Mr Chan want doctors to NOT be safe and comfortable? Or does he want pharmacists to NOT prescribe the medications 'as prescribed' by doctors?

Secondly, the prices of branded medicines from your doctors and from the few privately owned pharmacies in Singapore are the same. It's a waste of time to ask for prescriptions from doctors. Eg, I pay $4 a tablet each day for Plavix, a 'new and better' blood thinning drug, after my bypass operation 12 years ago, as compared to $1.70 a tablet of Ticlid and 5 cents a piece of Cardiprin. Is Plavix so good that it can displace the time-proven Cardiprin?

Plavix is not Ticlid is not Cardiprin. The difference between them is not that of branded and generic. They are different drugs, and have subtly different indications. Some patients cannot take Cardiprin or Ticlid because of side effects or allergy or risk factors, some doctors prescribe Plavix because they are proven to be better for the patient's condition.

Health Minister Khaw Boon Wan has said that if the generics costing a fraction can do the job, why pay for the branded?

Because some drugs do not yet have a generic form. Unfortunately new drugs are covered by the same concept of Intellectual Property as movies and computer software, and to manufacture and sell them before their patent run out is to commit a sort of drug piracy.

Thirdly, due to controlled high margins of profits in branded medicines, both doctors and branded medicine suppliers would refrain from prescribing and importing good generics to protect their interests.

Now that's a bold accusation. Against doctors, that is. Not all doctors prescribe branded drugs, and not all doctors have 'interests' in prescribing branded drugs. As Oz Bloke has mentioned before the margins on generic drugs are actually higher than on some branded drugs, and of course they cost less to stock. A doctor who wants to make a quick buck may in fact stock cheap, popular generics, mark them up by a high margin but still keep the selling price 'affordable', and aim for high turn-over.

If indeed doctors and medicine suppliers controlled the import market, wouldn't we simply import cheap generics and not branded drugs at all, but sell the generics at the price of the branded drugs instead?

The multi-million-dollar pharmaceutical industry has virtually controlled the market for more than five decades. It is high time that shackles be liberated. We need prompt and effective action with mandatory recommended prescriptions for patients to purchase medicines of their choice - either branded or generic.

Shackles? That's a bit dramatic. And it's multi-billion-dollar industry, actually. Like I said some drugs are simply not yet available in generic form. And even if they are, not all generics are the same as the original drugs (especially those with a patented 'delivery system').

I urge the Government to pass legislation for separate consultation and dispensing so that patients can choose the cheapest source for their medicines.

Paul Chan Poh Hoi

I have nothing against separating consultation and dispensing, but as others have noted on this blog before this may not necessarily lead to lower costs for the patients.

If the problem is that the medicine importers control the import and the prices, how would preventing doctors from prescribing lower costs when the seller can still maintain a high price?

Are the prices of drugs high? Yes, for some drugs. But are they too high? Well, that depends on what criteria you judge it from. But I take issue with Mr Chan's potrayal of doctors as people involved in a conspiracy to keep drug costs high for their own interests.

God knows I never benefit directly from prescribing branded drugs...

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  • Somehow I have a feeling this Paul Chan is in some industry that counters pharmaceutical drugs. If you get what I mean :wink:

    Anyway I have written before on forums about having a trial period where all GPs charged consult fees and only wrote prescriptions (generic names only). No dispensing. Patients would have to travel to pharmacies and buy their own medicines.

    The pharmacists can advise the patient on the drugs they want to buy (eg generic vs branded) based on the prescription. Just like the west!

    Then at the end of the trial period, let's see what the people want and see whether the overall cost (money, time spent travelling, convenience etc) is lower with that system or our current system.

    I know many GPs will be more than happy to stop having to stock drugs (takes time and manpower, headaches over expiry dates, physical space to stock them, dispensing, laws etc) and just charge the full consultation fees. Currently for short consults <10 minutes the guidlines states $20-$30. Many clinics are still undercharging eg $10 for consults. But overall bills for patients(inclusive of consult and all medications) is about $30-$40 (usually with generic drugs)

    If you ask me that's a bargain!

    Yes there are clinics that prescribe branded medicine but I doubt the total bil would be <$50! But everyone has a choice. If they don't want to pay so much, then don't go to those clinics. But you get what you pay for. Branded drugs don't come cheap.

    Doctors have nothing to do with this "consipracy" Paul Chan speaks of. As angrydr said, some drugs do not have generic version because the patents are still in force, but they are good drugs with good characteristics. If doctors started giving patients older generic versions with increased risk of adverse effects instead of the newer safer drug, then allegations of doctors being cheapskate at the expense of the patients well being can be made.

    Which is why I am all for writing prescriptions and pushing the dirty work to someone else. Perhaps the pharmacists? Haha! After a while I think the pharmacists would have bigger problems than they realize!

    By Blogger Dr Oz bloke, At May 27, 2006 12:39 pm  

  • I think the issue here is they don't understand the patent laws. But I do question the use of plavix. If I didn't remember wrongly plavix patent was extended. The patient is probably on ticlid for the longest time.

    By Anonymous Anonymous, At May 27, 2006 1:53 pm  

  • wa..i think what u said make quite a lot of sense..why dont u send a reply letter to the forum?

    By Anonymous Anonymous, At May 27, 2006 2:06 pm  

  • I don't understand patent laws fully either - the current Plavix patent legal wrangle is pending, and it sounds a little confusing to me. But then it's not about Plavix.

    Dr Chan has not named specific companies or doctors involved in this 'controlled' market, so I cannot run a search on the background facts. Until he presents us with facts to back his accusations up, we cannot be sure if he has a case or not. I am not saying that he is wrong and no such conspiracy exists, but I find that his arguments so far are not convincing. We need more facts.

    I won't write a letter to ST Forum to reply - the 'relevant authorities' will do that, and with more authority and facts than I currently have. MOH, SMA, and probably the HSA most likely already have staff on the job before I made my post this morning. I'll just post my piece on this blog with its small readership, where I can admit my mistakes more easily if my points turn out to be wrong.

    By Blogger angry doc, At May 27, 2006 11:00 pm  

  • It's an online letter so no reply needed.

    The problem with medicine nowadays is a one size fit all mentality
    Cost must come into place when considering medicine to prescribe.

    Those who can afford should have the best medicine which may or may not be the most expensive one available.

    Those who can't should have a choice of medicine that may not be as good but much cheaper. Then again patients should make a choice on what they want.
    Some may want the best despite them unable to afford it

    By Anonymous Anonymous, At May 28, 2006 12:37 am  

  • Perphaps I worded it wrongly. I think the general consumers don't know the difference between patented drugs and generics. They think they can get people to manufacture generic drugs so that consumers have a choice between the patented product and the lower cost generics. They can only have that if the patent expires. Of course in countries like india and indonesia you can probably get all the generics even if the drugs is still patented. Just that on one is going to guarantee you are getting the real stuff.

    By Anonymous Anonymous, At May 28, 2006 12:48 am  

  • I totally agree with trying out the "new" system for a while. Rest assured, within 6 months, patients will realise that our current system serves them best. Ultimately, every clinic / business has a minimum day-to-day running cost. A certain minimum "amount" MUST be earned from each patient. Currently, this "amount" comes from the consultation and earnings from the medications. If clinics cannot earn anything from medications, of course, the full amount will have to be earned from the consultation portion - current situation in the west where a GP's consultation costs US$50.
    In addition, they will also have to pay for the pharmacies' running costs ! Double whammy !
    And, as previously posted, the time, and costs incurred to travel to a pharmacy.
    Silly people who think that they can save by separating consultation from dispensing, should imagine themselves ill with eg GE. Imagine having diarrhea and abdominal pain, and you have to travel to a pharmacy because new MOH rules forbid clinics to dispense medications.
    The same silly people should also realise that pharmacies hardly carry generic products! So, they end up paying for branded stuff even for the most simple ailments.
    I personally only use certain branded antibiotics instead of cheaper generics, because personal experience has shown that the generics are not as efficacious despite all the studies that they publish - I have seen patients who are worse off despite being on the correct dose of a really cheap generic - not just once, but several different patients.
    So, all of you lay-persons out there, would you rather trust your doctors' choice of brand of medication, or go to the cheaper clinic and suffer for a longer period? - of course assuming that the Dr is using a particular brand because it is better, and not because it earns him more.

    By Anonymous Anonymous, At May 28, 2006 11:50 am  

  • Mr Chan sounds like he doesn't understand the nitty gritty of the pharmaceutical industry & patent laws & why some drugs have generic versions & some don't. He obviously doesn't know that the profit margin from generics is often much greater than that for branded drugs. I know the pharmaceutical companies get bashed a lot for the high prices they charge for the drugs they produce, but looking at it from another angle, a lot of money is spent on R & D in developing these drugs.

    By Blogger aliendoc, At May 29, 2006 9:01 am  

  • A lot of money is spent on R&D, but more money is spent on marketing, and of course they do make a handsome profit.

    By Blogger angry doc, At May 29, 2006 9:16 am  

  • So to summarise, the problems are :

    1) People do not understand the reason for high price of branded drugs eg patents, R&D costs

    2) People do not understand the difference between branded and generic drugs eg when a branded drug can become generic (ie Patents again)

    3) People do not understand that there is a difference between branded drugs and generic drugs in terms of drug properties, safety profile etc and not just price

    4) People do not understand that the current system of letting GPs dispense is actually a boon to them in cost savings and convenience and a hindrance and burden for GPs.

    So can we start an "information drive" to let people understand these things better? HPB?

    By Blogger Dr Oz bloke, At May 29, 2006 10:52 am  

  • People in Singapore do not realise that their GPs are sacrificing huge amounts to go on pleasure cruises and for expensive dinners to learn about the latest and best anti-hypertensives. They are ungrateful and do not realise that if they took generic drugs which have been shown by large clinical trials to reduce mortality rather than branded drugs prescribed by the wise GP, they would bring untold harm to the doctor patient relationship.
    Silly Singaporeans

    By Anonymous Anonymous, At May 31, 2006 10:18 am  

  • May Paul Chan and all those who think like him RIP (respect intellectual property).

    By Anonymous Anonymous, At May 31, 2006 10:50 am  

  • Drugs which are still not off-patent aside, anon's scenario (of the drug companies bribing doctors to prescribe branded drugs rather than generics in an open market) is definitely more believeable than Mr Chan's version (of a situation where doctors are drug importers have a stranglehold on which drugs may be brought into the country and prescribed).

    For one thing, we know that there are GPs who prescribe generics, and there are pharmacies that stock generics.

    By Blogger angry doc, At May 31, 2006 11:17 am  

  • Mr Chan is just sore that he had to pay for his Plavix instead of Aspirin or Ticlid. Wonder why can't he talk to his doctors but instead had to write to ST forum?

    Maybe he is trying to show us that the general public is as sotong as he is?

    By Anonymous Anonymous, At May 31, 2006 11:42 am  

  • Sometimes I think the ST Forum's mission is to show us how ignorant/selfish/vindictive Singaporeans are.

    By Blogger angry doc, At May 31, 2006 11:47 am  

  • Switch him back to ticlopidine so he can enjoy his bd dosing as well as his blood testing for neutropenia

    By Blogger dan, At October 08, 2006 11:49 pm  

  • I take issue at the implied slight that the place across the causeway is awash with fake drugs and things.
    Its time Singaporeans dispense with the idea that you are the premier country in this region. Lately you are begining to look like some backwater region of our country.

    By Anonymous Anonymous, At July 23, 2007 8:50 am  

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