Former pharmacist here. I think most doctors do try to be cost conscious for the patient. But there are some who prescribe the newest and expensive brand name drug, and I can’t think of any reason why except some sort of incentive program.

Many ophthalmologists will give the most expensive post surgical drops. When I called one to have him change it, he was like “uh, there’s no substitute.” I thought to myself, “then what did you guys do before these drugs came out a couple months ago?” Example: post cataract surgery people usually get an antibiotic, a corticosteroid, and an anti inflammatory. These generic drugs have been on the market for years. But new ones come out here and there that are hella expensive, we’re talking a copay of $5.00 vs $100+ per eye drop.

Also there are prescribing guidelines called step therapy. For example for diabetes: https://emedicine.medscape.com/article/117853-treatment#d10 doctors will skip the first few steps and prescribe a brand name drug immediately that’s like step 3.

Insurance companies try to stop it by requiring authorization but... I feel like we’re fighting an uphill battle with perverse incentives.

In my former job, I talked to a lot of doctors about this stuff.

What I found was that a lot of doctors look at the decision from a clinical lens only. Why not prescribe the latest branded product, even if it's only marginally better than the generic? Patients deserve the best, right?

Making a cost vs. benefit trade off wasn't a universal process for many physicians.

I've actually run into a very similar example, I was prescribed a $400 dollar bottle of antibiotic eye drops, which my insurance fought and eventually paid for. I asked why that was chosen and if there were other options that I could pursue in the future. I was told that "these are your eyes and I'm not going to [fuck around] when it comes to your vision."

I can't really disagree with that logic.

True, but what did doctors do before these new drugs? “Fuck around” with “inferior” products... reason I’m cynical is because many new drugs that hit the market are not novel - for example loteprednol (older drug) vs difluprednate (newer): https://www.ncbi.nlm.nih.gov/m/pubmed/28628490/

By the way, some of these newer drugs don’t have to be “superior” to be approved, they just have to be none-inferior to current therapy. https://www.raps.org/regulatory-focus™/news-articles/2016/11...

From what I gathered, it was more effective than the cheaper options, not that it was chosen because it was new and shiny.