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2010-03-09 issue:

The cost of medicines

You can do something about it.

by Glen E. Miller

Print Article

The dilemma: You go to a doctor with a specific problem. After your consultation, the doctor tells you that you need a certain many-syllable medicine. You trust the doctor to know what toprescribe, but the cost of the pills is astronomical. What can you do?

An office visit—Part 1
I went to see my cardiologist (yes, even doctors go to the doctor sometimes). The cardiologist said I needed an antibiotic for the cough I’d had for three weeks. He asked me if I had drug insurance. When I replied that I did not, he said, "Well, that rules out the medicine I was going to give you because it costs $550 for a 10-day supply." He decided to give me a medicine that costs "only" $110. When I asked about the less expensive medicine, he said, "Actually, the $550 antibiotic is a repackaging of an older form of the same medicine. The pharmaceutical companies do that to extend the patent so they can charge a higher price." He assured me that the older medicine was just as effective as its newer, more expensive form.
The older antibiotic cleared up my cough. I decided to question my doctor when I returned (see "An office visit—Part 2" below); I wanted to find out why he would even want to prescribe a medicine that cost five times more than the one he ended up giving me.

The patient's point of view
As consumers, advertising plays a role in fixing certain drugs in our minds (and in doctors' minds) as the medicine for a given condition. Some patients want the latest drug they learned about from an ad during a Bears-Colts football game or on the evening news. You may appreciate it when your doctor gives you a starter sample of a new drug, but you may end up paying more for filling the full prescription for the new medicine than you would have paid for a generic alternative.

Many patients assume their doctor knows the details of their insurance policy. This may not be the case. Your doctor is probably unaware of your policy's specifics, such as the amount of your copay and whether or not you carry any supplemental insurance, such as prescription-drug insurance.

Some people may not feel comfortable talking about money with their doctor. One woman said she did not want to be perceived as questioning her doctor's authority regarding medicine. She spoke with her pharmacist instead, asking the pharmacy to call the doctor to find out if a less expensive alternative was available.

The doctor's point of view
Most doctors are busy people, and unless you bring up the subject of cost, it may not be discussed. You should not assume your doctor is giving you the least expensive form of the medicine. Doctors are well aware of the recently instituted "$4 per month per drug" put forth by pharmaceutical companies and may prescribe with that in mind. (See list below) However, patients should not assume that is the case.

Many doctors have stopped seeing drug representatives and accepting favors. Providers who work with mentally ill patients may continue to see drug reps because they need the samples as starter medicines. For these patients, the cost of medicines in some cases needs to include the cost of blood tests to monitor the effectiveness of those medicines.

How do doctors decide what to prescribe? According to studies, a doctor will generally remember several medicines for a given situation. Say you have a nasty cough. Your doctor will recall the drugs to treat bronchitis, think about each drug's effectiveness as applied to your case and weigh that against possible side effects. Most doctors seldom consider the cost of the medicine they prescribe.

Likewise, few doctors prescribe medicines because of the drug company that produces them. Drug companies hope their marketing will create a fixed response in a doctor's mind. When you come into the office with knee pain due to arthritis, it may be that Advil automatically springs to your doctor's mind as the medicine of choice. Doctors tend to remember most drugs first of all by their proprietary (more expensive) names rather than their generic (less expensive) names. For instance, Zocor may more readily spring to mind for the treatment of high cholesterol than the generic name Simvastatin.

An office visit—Part 2
When I saw my cardiologist six months later, I reminded him of our previous conversation and asked, "If you felt the older, cheaper medicine would do just as well, why did you initially prescribe the newer medicine that was five times more expensive?"

The good doctor went into a rather long explanation that can best be summarized by saying he thought the newer medicine is what I would want. After I expressed my concern about the high cost of health care in general, the cardiologist looked over the other medicines I was taking and changed one of them to its generic form. This change reduced the cost of that medicine from $1.85 to $0.59 per day—a savings of $463 per year.

Later I took advantage of the special drug company offer of $4 per month per drug and saved an additional $167 per year on this medicine for a total savings of $630 a year—or $52.50 per month.

Remember …
Several things should now be clear. Doctors don't automatically pay attention to the cost of the medicine they prescribe, they likely won’t know your insurance status and they feel the pressure of a limited amount of time with each patient. As a result, you may be given a prescription for medicine that is the most expensive when another, less expensive medicine may be just as effective. You, the patient, need to ask about the cost of medicine so the cost automatically becomes part of the decision of which medicine is best.

Glen E. Miller worked as a primary care physician and administrator more than four decades, mostly in Ohio. He’s a member of Assembly Mennonite Church in Goshen, Ind. This article is excerpted from his book Empowering the Patient: How to Reduce the Cost of Healthcare and Improve Its Quality (Dog Ear Publishing, 2009). See empoweringthepatient.com.

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Additional Notes

What you can do to reduce the cost of
prescription drugs

1. Tell your doctor that the cost of health care is important to you and that you want to know about the cost of tests, procedures, services and medicines.

2. Recognize that the newest medicine may not be the most effective.

3. Ask your doctor for generic drugs when available.

4. Ask your doctor for larger prescriptions that will last for a longer period of time and will result in lower cost of the medication per day.

5. Take advantage of drug companies' special offers. Check with your local pharmacy about a "$4 per month per drug" limit on prescriptions (those covered can be found online). An annual fee for a $35 card was established by many pharmaceutical companies in 2008 and renewed in 2009.

6. Check prices of medicines online. Then in light of your research, you can ask the doctor's office to fax a prescription to your pharmacy.

7. Get the larger size pill and split it in half to get the same dosage of medicine at a reduced cost per day.

8. Check http://www.consumerreports.org/health/best-buy-drugs/index.htm for a comparison of the efficacy and cost of drugs for specific conditions.

9. See Chapter 19 of my Empowering the Patient, "Prescription Drugs:
How to Bring Them Under Control," for more information on why medicines cost so much.

By Glen E. Miller

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