Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, July 03, 2007

What Part of "Cheap" is So Hard to Understand?

  • Prescription drugs are expensive.
  • Doctors don't know how much drugs cost.
No argument there. Doctors are systematically and intentionally prevented from getting too precise a handle on drug prices because then we might be tempted to try and talk someone OUT of a prescriptions for Levaquin for that cold.

Seriously, from a sales standpoint, prescription medicine is unique. Think about it: despite the fact that all sales figures are dependent on my actions, I neither use nor pay for the product. Same goes for medical devices. Crazy.

So when some of us go out of our way to discover that certain old but extremely effective medications are not just inexpensive but downright cheap -- and then actually make an effort not only to prescribe them but explain to the patient why such old, cheap drugs are really an excellent choice for their mild hypertension -- exchanges like this become frustrating as all hell:

Patient on phone: "I need a refill of my HCTZ 12.5 mg."

Me: "I gave you a prescription for 90 of them in March. You should still have refills."

Patient: "But my pharmacy said my insurance would only cover 30, so that's what they gave me. And now I'm out of refills."

Ok: let me interject here that *perhaps* it costs a little more to fill 90 teeny tiny capsules with 12.5 mg of a drug that costs about $5.00 for one hundred 25 mg tablets than it would to purchase 45 said tablets and break them in half. I'll even grant you that not everyone wants to be bothered splitting pills. Still. What the hell happened to the other 60 capsules from each prescription?

No way around it: I have to write another Rx as I explain (yet again) to the patient that the medication should be very inexpensive and perhaps she should consider switching pharmacies. Or offer her the opportunity to split her pills. As it turns out, the real problem is that her insurance company now insists that she get them by mail order.

People have become so conditioned to the idea of "insurance" that they don't even realize the don't have to use it. All it is, after all, is a way to help pay for expensive medicines. But when the meds really are dirt cheap, no one even thinks of telling the pharmacist, "Never mind; I'll just pay for it." Then again, I'm pretty sure there are pharmacies ripping people off right and left for their HCTZ, atenolol, lisinopril, and all my other first-line generics.

Put that in your pipe and smoke it, all you folks still blaming me for your drug costs.


At Tue Jul 03, 10:26:00 AM, Anonymous Anonymous said...

Hi. I love your blog. Not sure how I found it but I've been lurking a while. I'm not in the medical profession but have always been interested and, being a mother, have plenty of experience with doctors, insurance, and the like. You have a very refreshing perspective.

Anyway... all that said. I'm going to comment on the post :)

I had a situation with the pharmacy a while back where my copay was $10 but they were having trouble and couldn't get their online stuff to work and get confirmation, etc. so they said I'd have to wait for the script. It was for my son who was quite sick and needed it now. So I asked what it cost without insurance. $9.95. "Uhh... I think I'll just pay for that." Were they seriously asking me to wait!?!?

We are often conditioned that we can only do what is allowed by insurance and use what is on their plan. Not every medical test or every medication is expensive. Sometimes it's worth it to ask. At least you're making an informed decision.

At Tue Jul 03, 10:48:00 AM, Anonymous Anonymous said...

I'm not sure my pharmacy would let me pay out of pocket without filing a claim with insurance. And I'm not so sure my health plan would allow it either.

I don't think it makes much sense. My drug co-pay is $25 per prescription. The only medication I'm on is generic l-thyroxine, which costs less than $25, which means I am paying the full freight every single time I refill. Yet the claim is always filed with my insurance and I get a quarterly statement showing what I've paid and what insurance has paid. Someone needs to push paper around in the name of accountability, I guess.

I should point out that aside from the co-pay, everything that patients spend on prescription meds applies toward their annual deductible. So if you are someone who has a lot of routine medical expenses or who is dealing with an expensive chronic or acute condition, it is to your financial advantage to file the claim with your insurance so you can get credit for your out-of-pocket expenses that apply toward your deductible. If you don't have a lot of medical expenses, it's probably no big deal... but for some people, it really can make a financial difference.

Weirdly enough, if I could get a 60-day or 90-day refill, insurance would probably pick up some of the tab, since the bill would then come to more than $25. But they have refused to authorize more than a 30-day supply. Gee, I wonder why.

My parents switched to a different Medicare supplement last year and they were *required* to get their drugs by mail-order. They are not allowed to get more than a 30 days' supply.

I have run into problems when I needed to refill "too soon," e.g. planning to travel and need to make sure I have enough medication while I'm on the road.

So I wonder what gives? Is this just a way of payors keeping tabs on patients so we don't abuse our drugs? I am paying for all of my medication out of my own pocket so they frankly have no right to butt in... yet here they are, dictating when and how much I can refill. Stupid.

With all due respect, in response to your final statement, I think docs have brought some of the complaints on themselves because they control the prescription-writing. L-thyroxine is not a particularly dangerous medication and it's not overly hard to tell when you're overdosed or underdosed. Yet whenever I need to have my prescription renewed or titrate the dose up or down, I have to go through the whole rigmarole of calling the physician, leaving a message, having my TSH checked, waiting for the results, blah blah blah. Why can't I have more control? Why can't I just buy l-thyroxine over the counter? I know there needs to be some accountability here, but I think docs want to eat their cake and have it too. I don't like the system any more than you do, but I don't see the medical profession being very willing to give up some of their monopoly on writing prescriptions.

It's all a power game, and patients are being held hostage and I'm sick of it.

At Tue Jul 03, 11:31:00 AM, Anonymous Anonymous said...

It is very difficult to pay for prescription with cash. The patient has to work at it.

I take Armour thyroid - an old, cheap drug that works. To pay cash, I get that prescription filled at a totally different pharmacy where I've never used insurance... and they still ask for my insurance card. I ask my doctor to write for 100 pills (the way the manufacturer packages it) for an additional 10% discount... and they still ask for my insurance card.

I sometimes get veterinary prescriptions filled at the people pharmacy, usually for a low-dose old, cheap ACE inhibitor. Even when I tell them repeatedly that the patient is a dog, even when the prescription is made out for Dog's Name K9 My Last Name, they still ask for my insurance card. On that front, I finally handed it over and said "Good luck with that."

My advice is to phone around for cash prices beforehand. You'd be amazed at how much the cash price varies not just between pharmacy chains but between locations.

At Tue Jul 03, 11:53:00 AM, Blogger Bookhorde said...

There's another issue - information. If you buy any medication without going through insurance, you (patient) better be sure you make a note of it and let the insurance company, or future insurance company, know. Otherwise it might look like you are hiding a pre-existing condition if/when you need to get new insurance.

At Tue Jul 03, 01:31:00 PM, Blogger tk said...

When I went on vacation for almost the entire month of May, it was too soon to refill my HRTs, so I paid cash. I didn't have any problem at Walgreen's paying cash when they already had my prescription. With insurance, I pay a little over $5; without insurance it cost me a little over $16. My insurance wouldn't make an exception to fill early due to my vacation plans (big surprise).

Anyhow, go to Walgreen's for your prescriptions, and you shouldn't have trouble paying cash when necessary--they were very friendly about it.

At Tue Jul 03, 06:51:00 PM, Anonymous Anonymous said...

"As it turns out, the real problem is that her insurance company now insists that she get them by mail order."
Actually mail order is likely to avoid 30 days vs 90 days problem. Medco-health, for example, want prescriptions for the 90-day supply with refills up to the end of the year. So no problems getting 90 days supply. They also provide a chart comparing both out-of-pocket and insurance cost of similar drugs so for every prescription you can click on a button and they show you a table of cheaper alternatives that you can either ignore or print out and take to the doctor.

Even when I tell them repeatedly that the patient is a dog, even when the prescription is made out for Dog's Name K9 My Last Name, they still ask for my insurance card.
A bit off-topic, but I cannot resist telling a funny story about a vet prescription. My co-worker had an ex-stray cat with a spraying problem. The vet prescribed Valium. As usual with vets, the prescription was written using cat's first name and owner last name e.g. Fluffy Smith. A pharmacist ignores DMV and very strange sounding first name and the following conversation ensues:
- This is a very strong medication
- Uhm, ok.
- How do you administer it?
- Very simple. I grab him, open his mouth and my wife shoves it down his throat.
At this point the pharmacist looks totally shocked and ready to call child services. So my co-worker says - "it's a cat!".

At Tue Jul 03, 06:52:00 PM, Anonymous Anonymous said...

Oops, I meant DVM, not DMV...

At Tue Jul 03, 08:32:00 PM, Anonymous Anonymous said...

"Why can't I have more control? Why can't I just buy l-thyroxine over the counter?"

I think it would probably be safe to say aspirin is safer than thyroxine, right?

Except 76,000 people a year are hospitalized for GI complications related to aspirin and other NSAIDs alone. Since socialized health care is the popular topic du jour, let's justify it on the grounds that we can't afford to pay for the hospitalization of all these self-medicators.

As for cheap meds, I would advice any physician in a primary care or similar setting to print out the Walmart list of $4 generics. You can get a surprising amount done with uninsured patients on $12; it's really been a godsend from the days of pharmacies jacking generics up to $15 or $20 each.

At Tue Jul 03, 10:46:00 PM, Blogger The Hatchling said...

As for the anonymous comment above, prescription pricing is above and beyond the responsibility of a physician. Its hard enough to stay current on all the advances in medicine, let alone to stay current on the best prescriptions. I've been told multiple times that half of the things I learn in medical school will be out of date by the time I graduate.

A physicians goal needs to be treating the patient which entails good bedside manner, diagnostic skills, and a fair amount of personality (which we do adapt depending on the patient).

We do our best with everything we can, but IMHO, that falls outside the line of mandatory for what a doctor should be doing.

At Wed Jul 04, 04:33:00 AM, Anonymous Anonymous said...

God, I love living in Wales (UK) where all prescriptions are free!

I wouldn't survive otherwise. 9 tablets of Colizide a day!

At Thu Jul 05, 12:20:00 PM, Blogger Pam B-W said...

Great blog, Doctor!
First, a 90-day prescription these days can only be filled at a pharmacy benefit manager (PBM) mail-order pharmacy. More profit to the middleman, don't you know.

Second, make friends w/a pharmacist, not a drug rep, and you'll have a handy reference for those less-expensive yet still effective older drugs.

Third, here comes the middleman again. I don't know of an insurance company that doesn't use a PBM. PBMs make money by selling drugs for which they have a sweetheart deal with the manufacturer to distribute. Again, more of your patients' healthcare dollar going to anything BUT actual health care.

And fourth, the only solution to this "stuff" is a single souce payer. Don't cringe, Doc. It'll cut big bucks out of your overhead if you don't have to employ umpteen staff to fight and beg for your own reimbursements. And your patients might even come to you because they like YOU, not because you're the only doc on their insurance plan taking new patients!

A consumer with way too much experience in these matters,
Pam Baggett

At Thu Jul 05, 12:58:00 PM, Blogger Joeymom said...

Since I live in a world where most of the care my son needs isn't covered by insurance, anyway, I tend to ask first. "How much is this medicine? How much is this service? No, no, assume I'm private pay, I'll decide whether to use the insurance or not, thanks..."

I usually get a lot of "ums", "I don't knows", and incredulous looks, as if I am trying to do something illegal. It's annoying.

At Thu Jul 05, 03:06:00 PM, Blogger Radioactive Tori said...

Because of the thyroid cancer and needing to keep my TSH at exact levels, I take different doses of Synthroid on the weekends as I take during the week. They ALWAYS mess up my prescriptions because it is so odd to need a supply of just 8 pills for a month. The first time I went to pick up my 8 tablets for one month of weekends, we discovered it was cheaper to not use the insurance for them. They still mess up my prescription every single time, but at least now once it is sorted out I get it for cheaper than if I used the insurance. My son takes a lot of medicines that are cheaper without the insurance as well. It is a hard habit to get into to ask how much things are without insurance, and you do get some strange looks sometimes, but it is worth it if it can help save some money!

At Thu Jul 05, 05:18:00 PM, Blogger Richard A Schoor MD FACS said...

I just had a great insurance experience. I switched plans and with it my rx coverage. When I went to refill nexium, the pharmacist said I had to jump through about 20 hoops to get it. I tried prilosec OTC, an enantiomer of nexium, for 20 bucks for 30 pills. Less than the copay for nexium, had it been allowed. You know what? It works just fine. Who knew? I never tried it. And like everyone else, I feel prey to the 1st tier vs OTC BS.

At Fri Jul 06, 12:42:00 AM, Anonymous Anonymous said...

I pay cash for every thyroid prescription I get. 90 Days worth is $21 at Sam's club. My co-pay is $20 for 30 days. You can insist on paying cash - it is your right. Stand up for yourself.

At Fri Jul 06, 12:43:00 AM, Anonymous Anonymous said...

Dont ever go to Walgreens, or even CVS. Prices are jacked way up. I dont live in a place where we have Costco's, but I read and hear they are reasonably priced. G to Walmart for drugs, the 4 dollar plan covers alot and the other drugs are cheaper than retail pharmacies. No Walgreens, dont get sucked into that trap

At Sun Jul 08, 09:44:00 PM, Anonymous Anonymous said...

ANON 7/3 10:48 AM

"Why can't I have more control? Why can't I just buy l-thyroxine over the counter? I know there needs to be some accountability here, but I think docs want to eat their cake and have it too. I don't like the system any more than you do, but I don't see the medical profession being very willing to give up some of their monopoly on writing prescriptions.

It's all a power game, and patients are being held hostage and I'm sick of it. "

You had part of an answer from the reply about Aspirin.

The other parts to your answer:
1. the doctors are not playing power games with you; they are the ones held liable for treatment gone awry and unmonitored.
2. wait until a "mishap" occurs in your thyroid hormone replacement therapy; this and other rx meds are not as benign as u'd like to think; when you get the misfortunes of un-monitored adjustments [or none] to your regimen - that will be the penultimate proof to you what u are being warned of; right now, you'd probably look at this as a scare tactic / power game you are blaming your doctor[s] for...but wait till you experience it; then your doctor will still be the bad person for telling you :'i told you so...'; doctors cannot win for losing...

At Mon Jul 09, 04:06:00 PM, Anonymous Anonymous said...

These comments confuse me. I work in a pharmacy, and have no problem suggesting to patients that maybe they should pay cash on certain drugs, so they can get a 90 day supply for their 30 day copay (assuming the doctor wrote for a 90 day supply, of course). You come in to my store and want to pay cash? I charge you the cash price. It's easy, really. I will be sure and warn you ahead of time if it's a pricey drug.

And the reason we always ask for your insurance card is because we've been yelled at so many times by someone who just paid $16.99 for their whatever, when they could have paid "just $15.00!" with their insurance - that they don't have their card for and didn't say they had. Most people expect to their drugs at a low copay, and if for some reason it doesn't happen, then it must be the fault of the poor sap behind the counter. In other words, it's a self-preservation tactic.

At Mon Jul 09, 05:18:00 PM, Blogger #1 Dinosaur said...

Pharm tech: You react to these comments the same way I react to rants about inconsiderate docs who keep people waiting for hours and don't return phone calls.

Those of us who are good at customer service are stuck being blasted by those who have had bad experiences other places. (Because of course, *every* pharmacy -- and every doctor -- is exactly the same as every other.)

At Wed Jul 11, 12:40:00 PM, Anonymous Anonymous said...

I have been getting my wifes drugs through Caremark. We just paid $20 for 90 pills and then I find out 100 exact same pills are $10 at Costco. How can they call this insurance? You pay a premium and then you pay them a profit for the drug!

At Wed Jul 11, 04:42:00 PM, Anonymous Anonymous said...

All right then, anony from July 8: You made your point (quite well, actually) and I get it. I just like to play the devil's advocate sometimes, because, you know, patients are so often caught in the middle and have the least amount of power of anyone in this equation.

I've had chemotherapy and XRT, so yes, to me l-thyroxine looks comparatively more benign. It's all relative, I guess.

I do respect my medication and would not tinker with it unless first consulting the doc. If I ignore his advice and something goes wrong, it's on me. Some of us, believe it or not, were raised by our parents to take responsibility for our own actions, and would not seek to blame the doc for failures of judgment that lie with us alone.

I call it the "Suck It Up School of Life."

At Thu Jul 12, 11:55:00 PM, Anonymous Anonymous said...

Hmm... maybe things are different in the state where you practice, but in my state if the doc writes for 90 pills and the patient only gets 30, that doesn't count as a full refill. The patient can still get the remaining 60 pills on fill #1 without using up refills. Their Rx label will say "3+ refills left before [date]." After the first 90 pills are dispensed, they've officially used up a refill, so when they get their fourth month's supply it's "2+ refills before [date]."

Unless, of course, the drug being prescribed is a controlled substance, and then you get to refill it 5 times, PERIOD. If some or all of the fills were for less than the full amount, too bad so sad.


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