Archive for October, 2013
Elisabeth Rosenthal wrote the lead story for The New York Times today (10/13/13) “The Soaring Cost of a Simple Breath“. This is another blockbuster exposé of drug costs that are crippling US health care. Sadly, not a story about what is being done to correct the problem.
Here are some of her key points:
- The average brand name prescription has risen from 1995 at $40 to 2013 at $170
- The average generic prescription has risen from 1995 at $20 to 2013 at $45.
- A common asthma medication Pulmicort costs $175 in the US but only $20 in the UK and $25 in France.
- Drugs account for 10% of the $2.7 trillion annual health bill.
- Americans take more generic medications than people in other countries (they just can’t afford branded or new medications)
- Other countries set the wholesale price of drugs to make drugs affordable.
- US pharmaceutical companies have used the FDA to restrict manufacturing rules to favor large companies and have used the judicial system to bankrupt competitors.
- US pharmaceutical companies have paid generic companies not to sell their products in the US.
- Medicaid, paid for by taxes, pays millions of dollars to drug companies for high priced medications.
- Asthma medications have been the target of profiteering drug companies. Not a single inhaler is available as a generic. Despite the fact that inhaled medications have been available for over 30 years. The effect on people with this condition is a tremendous burden.
- Drug companies spend about 50% of funds on marketing and only about 20% on drug research. Other advanced countries prohibit marketing prescription medications directly to consumers.
- Medicare is prohibited from negotiating prices.
- Drug prescribing guidelines published by the government are prohibited from considering cost.
Rather than just be angry about the sorry state of drug costs, what can be done? Just take a lesson from other countries, this is not rocket science:
- The US government should set the prices for all drugs
- The FDA needs to loosen the rules for generic manufacturing — for goodness sake, an inhaler is an inhaler, not the space shuttle.
- Comparative effectiveness research should be required, and the results published for doctors as in the UK. Drug cost is important to all US citizens, so restricting the government from considering cost borders on insanity (perhaps giving psychiatric medications to Congress is currently too expensive).
- Finally, there is no excuse for the current drug cost problem — other countries have solved the problem, the US needs to do the same.
The above prescription example comes from Medical School Headquarters intended as an example of what doctors should NOT do — that is to issue handwritten prescriptions. There are just so many possibilities for error mostly coming from illegibility. Also, errors from inadequate information provided to the pharmacist and the patient.
Electronic prescribing is unquestionably the best solution. Patients should choose prescribers who use computer software to send prescriptions to the pharmacy. In fact, prescribers who don’t use computers to do this are dinosaurs soon to be extinct — perhaps it would be a good time to leave that office practice and find something more modern.
You might think electronic prescribing solves all the problems, NOT SO. Just ask any patient taking a few medications on a regular basis! Here is what they say:
- My office appointments never match when prescriptions expire –so I either have to change appointment times or hope the office will renew the prescription early — always involves a phone call and wastes my time.
- I had no idea the doctor prescribed a brand name drug instead of a generic and I got hit with an unnecessary huge bill.
- The doctor has no idea how much medications cost.
- I need 90 day prescriptions for some things and 30 day prescriptions for other things but they can’t get it straight.
- My doctor’s computer system can’t send things to my mail order pharmacy
- I have to send prescriptions to my mail order pharmacy myself — usually they are the handwritten type and sometimes the pharmacy can’t read them.
- If my doctor issues a duplicate prescription so it will last until my next visit sometimes I get more medication (and cost) than I need.
- Often generic medications are less expensive if I purchase them without involving insurance — the pharmacist sure does not tell me that!
Here are some prescription suggestions for PATIENTS:
- ALWAYS take a list of prescriptions with you to health care appointments (or just take the bottles, but there is a risk of loosing expensive medications in the process).
- Your record should include the name of the medication (brand name if appropriate) and generic name
- Dose — that means the size (mg) of the pills and number taken, or amount of liquid (ml) or strength (%) of a cream or ointment
- How often taken and whether scheduled or as needed
- Why the medication is taken
- Number of doses of medication prescribed AND exactly how many days that covers (like 30 day supply)
- When that medication will expire and need refill
- The pharmacy phone number and FAX number (the latter is very important for mail order pharmacies)
- ASK if a new medication is generic and if not if a suitable generic is available. Or, if a suitable generic in the same drug family is available.
- ASK if the medication is short term or long term. If it is long term usually ask for 90 day supply with 3 refills (if insurance will approve). And, use mail order services advised by the insurance company since they are usually less expensive.
- BEFORE leaving the prescribers presence ask if the number of refills on a new prescription will last until next appointment? And, ask for an extension of refills for older prescriptions that will expire before the next scheduled visit (otherwise you get the fun of calling the nurse for refills)
- If a specialist prescribes a medication ASK if the specialist plans on long term follow-up and providing refills — if not what communication with primary care will convey the needed prescription information. But, if the specialist plans on managing the medication expect a full review of all medications to avoid duplicate prescribing and adverse drug interactions.
Here are some prescription suggestions for PRESCRIBERS:
- Consider the cost of medications — you can’t do that if you don’t find out how much they cost, especially the brand name drugs
- Prescribe the lowest cost alternative. Before prescribing a brand name drug ask if you are sure there is a real cost benefit over an older generic. If you don’t know, find out.
- Don’t prescribe antibiotics for viral infections
- Think about refills, don’t just write some arbitrary number. Make sure the patient has enough refills and will not have to call your nurse to get them. Contrary to popular belief patients do not like to go the the pharmacy — give 90 day prescriptions where possible.
- Have a patient Internet portal to deal with medication refill issues.
- Although it’s nice to compute the number of pills a patient will need it is sometimes better for insurance reasons to say the number of days of medication is needed ( 7 days, 90 days etc.)
- To avoid duplicate prescriptions when the patients prescription will not last until the next scheduled visit the following statement is helpful “extend existing active prescription so refills last until ____ “(e.g. a year from today). Sometimes: “stop refills on current active prescription. This is a replacement so note the changes.”
- Most mail-order pharmacies will take either electronic prescriptions or faxed prescriptions — it is not rocket science to get those numbers into the electronic prescribing system — make it happen.
Finally, sloppy prescribing causes patient injuries, provider law suits, extra time, and extra costs for both the patient and the prescriber. Electronic prescriptions are a step in the right direction but they are now mostly geared for pharmacists and not the real-world problems of patients. The integration of pharmacies within care delivery systems (e.g. an ACO) is an urgent need.