I first realized something was amiss when I picked up my prescriptions and the pharmacist explained that she could not fill the anti-malarial medications as prescribed: “Your medication plan only pays for 30 days of pills, and your prescription was for five pills.” The pharmacist continued: “Your PBM [that’s an acronym for pharmacy benefits management company, the type of company that coordinates many peoples’ medication coverage] only fills this medication for 30 days at a time. And 5 pills would last 35 days.”
Expert logician that I am, I countered with some math of my own: “Well four pills, taken weekly, only lasts 28 days. If they really want to give me 30 days of coverage, they need to give me a fifth pill.” I thought it was insane to pay a whole extra co-pay to get my fifth and last pill, a co-pay I’d have to pay for my two sons too since all three of us were traveling together.
But the pharmacist was unpersuaded: “Sorry, four pills is it. You’ll need another prescription for the last pill.”
Irked, I handed over my credit card and hastily signed the bill, too bothered by the conversation to look closely at the bottom line.
When I got home and told my wife Paula about the saga of the fifth pill, she calmly looked at the bill and asked me: “If you were so concerned about a $10 co-pay, why didn’t you notice that the antibiotic you were given cost almost $200?”
Huh?
I should give you some background to this story. A couple of weeks before my trip to the pharmacy, my wife and I had decided to take our sons to Belize for the holidays. She travels internationally for her job, so she was up to date on all of her immunizations and was well stocked with travel medications. But the boys and I had to scramble to get ready in time. We had to start our anti-malarial pills before departing, for instance, and also needed to get typhoid and hepatitis injections early enough for our immune systems to respond. So we went to our family physician, a kind and personal man who had taken care of my boys’ ailments over the past year. He looked up Belize in the CDC website and prescribed everything we needed. Among the medications was an antibiotic we could take if we developed traveler’s diarrhea. That was the prescription that set me back almost $200.
I spoke with the physician after my trip to the pharmacy, to explain that we needed new prescriptions for the anti-malarial medications. He apologized for the screw up. I told him it was no problem, but I did wonder about the price of the antibiotics: “Did you know how much those antibiotics cost?”
“No,” he said. “I had no idea.”
“Couldn’t we have settled on a less expensive antibiotic?”
“Well I mentioned the name of the pill when I prescribed it,” he replied in a courteous tone, “and you didn’t have any objection.”
Okay, a bit more explanation here. I was a patient in this particular scenario, but I am also a primary care physician. It is often awkward for people like me to seek care from other primary care physicians. I worry that other primary care physicians will defer to me. But I don’t like the idea of being my own doctor. As the old saying goes: “The doctor who cares for his own ailments has a fool for a patient.” In addition, I worry that my physicians leave things unsaid when communicating with me, because they assume I can fill in the blanks. As in: “If I mention that antibiotic and he says okay, it will be because he knows what the alternatives are and agrees that this choice is best.”
That assumption was as wrong as a walk through a Belizean jungle without mosquito repellant. Because, you see, I know almost nothing about travel medicine. In my 15 plus years practicing in the VA health system, no patient has ever come to me asking for travel medications.
To be clear, I didn’t end up with expensive antibiotics simply because my doctor thought I knew what I was getting. Instead, as I talked to him further, he tried to justify his prescription decision: “Peter,” he said to me when I told him the cost of my drug, “I got back from a third-world country recently and the antibiotic I took there left a metallic taste in my mouth for a week. I would gladly have paid $200 to avoid that fate.”
“Good for you,” I thought. “But wouldn’t it have been nice to find out whether I, your patient, wanted to spend $200 that way?”
In the last few decades, medical schools have been teaching us doctors to inform patients about their treatment alternatives, so our patients can pick the alternative that best fits with their individual values. Which raises the question I’d love your input on:
Should doctors take the time to figure out the cost of treatment alternatives and communicate such information to their patients?
After you chime in with your ideas, I’ll take a crack at this question myself.
Peter Ubel is a physician, behavioral scientist and author of Pricing Life: Why It’s Time for Health Care Rationing and Free Market Madness. He teaches business and public policy at Duke University. Peter’s new book, Critical Decisions will be available in the fall of 2012. You can follow him on his personal blog.
Categories: Uncategorized
I understand that doctors already have a lot information to learn and understand through their profession. So is there a way, with our improving technology and all, to attach an estimated price range to a medication online? Doctors now use computers to prescribe medications, jot down notes, and print a comprehensive report of the visit for the patient. When they go online to prescribe a certain medication, couldn’t there be a line with the cost range so that they could inform patients then and there? And when this report is printed out, it would also be there for a patient to keep in mind.
Yes, it would be great if patients were informed of medication costs and their medical insurance plan coming into a visit, but there are simply too many medications from various pharmaceutical companies, that if a doctor were to simply run a name by me, I would have no clue where to start.
Should doctors take the time to figure out the cost of treatment alternatives and communicate such information to their patients?
That would be great, but an equally good start would be if doctors began a conversation with patients about costs, medications, etc, so at least there is an awareness.
I don’t think the doctors should be expected to be up to date up on changing cost of meds for patients. Medication can change depending on where you fill the prescription at.
It should be up to the patient to inform the doctor this med is costly what’s the alternative? The pharmacy and the patient should work together to find a patient an affordable alternative with the doctor’s approval. Some meds just don’t have a generic counterpart to offer the customer.
Maybe the doctors assistant could be more informed on cost to assist the patient.
I think if MD’s were at least a little informed on the price of the meds they were prescribing it would give the patient an idea of what they could be facing. Another thing would be to ignore the sales reps who come in selling the next “me too” medication. I work in pharmacy and every time a new med comes out we get patients coming in with free trial offer coupons, which is fine the first month, but the next month when they get a refill their copays skyrocket, and that’s if they have insurance at all. Which raises another point, one simple question, “Do you have prescription insurance?”, at the office would help tremendously. Many people bring a prescription in that with insurance would generally be reasonable, but without it’s a bit pricey. It’s amazing how many calls we have to make to the prescriber to see if they can change a medication because a patient can’t afford it, with or without insurance. It would save enormous amounts of time and money if everyone communicated with each other, and stayed informed about the treatment and treatment alternatives.
As the situation currently stands, a lot of the run around between prescribing physician, pharmacist, PBM, and patient could be eliminated if we started to encourage more patients to educate themselves on their individual health plans. As a pharmacy intern, it is impossible to immediately know the formulary medications, co-pay tiers, and prior authorization status of each drug we stock for each available health plan, much less expect our physicians to memorize that information when it is just a subset of their responsibilities. Pharmacy personnel are essentially the middle men in the situation, and in almost every situation we cannot manipulate a claim to have it paid without committing insurance fraud, however the PBMs’ role in controlling cost shouldn’t necessarily be viewed as an intrusion into the patient-doctor relationship either. They make individual plan information available for their clients to use when deciding what drugs are most cost effective for them, and it is usually easier to find a cheaper alternative (if desired) before the prescription leaves the doctor’s office, which is more likely to occur if we encourage patients to arm themselves with plan details at each visit that may result in a drug being prescribed.
I know we already demand much from our doctors and their staffs, but I do agree that they should be basically familiar with the costs of the medications they prescribe – at least enough to be able to alert the patient if one is unusually costly. I recently had outpatient surgery and was sent home with a prescription for a painkiller. My husband had it filled – at a cost in excess of $50. I needed one pill from the prescription. I reported this back to the surgical center and suggested they consider whether there are less expensive alternatives they can offer.
Doctor should not but the patient should. When a doctor makes a suggestion the patient should weigh cost, expected outcome and all other aspects of the care then make a decision. You can’t outsource this responsibility.
Every PBM we work with has this information available on their website. Patient could be sitting their with their smart phone redy to look up anything the doctor perscribes.
Would it be nice if the doctor had tablets for patients to use? Yes. Responsible for knowing the cost to every patient in millions of plans, no.
Always start with the generic would solve the problem for 80%+ of conditions though.
One problem is that the same prescription drug can cost very different amounts depending on your patient’s prescription drug plan. So the doctor could give you the cash price, but what one patient would be charged for the same drug after running through insurance could be very different. What may be very costly in one plan could be in a totally different tier in another resulting in a very different out of pocket cost for the patient.
I think it’s fair to ask the doctor the cash price, but then the patient and the payer (private insurer, medicare part D insurer, or the patient, all need to play a role to figure out how much that drug would cost to them).
“Should doctors take the time to figure out the cost of treatment alternatives and communicate such information to their patients?”
__
Yes. How is such information separable from relative likely outcomes?
Y’know? The “Informed consent” thing?
Moreover, perhaps patients (“consumers”?) will do better to ferret out such information themselves in advance, in order to be able to discuss such things with their docs.
And we are mystified that America’s market-driven medical care is expensive.
*Sigh…*