Medication Sticker Shock

Last week my office received a call from a distressed patient who went to the pharmacy to fill prescriptions following a hospitalization. The cost for a month’s worth of three medications she was expected to stay on indefinitely was over $800. With mortgage rates being what they are, most people don’t have mortgage payments that big. She called our office in a panic. As she related her story, I wondered how this fiasco could have been avoided. When I prescribe medications, either my EHR or my Epocrates program gives me an idea of what the patient’s price will be based on her insurance. Is that too difficult for hospitalists to do? That sounds sarcastic, but I’m serious. Are the logistics for a hospitalist such that running medication through software to determine the likelihood a patient can afford them not realistic? What about the pharmacists in the hospital? Could this become part of the discharge process?  Patients should not have to deal with “sticker shock” after a difficult hospitalization.

I changed two of her meds to inexpensive generics and called a cardiologist to ask what to do with the anti-arrhythmic. He told me that the new medication was only slightly better than placebo in studies. And for that she was paying over $300/month!

One of the Affordable Care Act provisions is that hospitals will be penalized for readmissions within a month of discharge.  It will become incumbent on the hospital team to have a better understanding of medication costs, one of many reasons why patients are non-adherent[1] with their therapy. As the family physician getting panicked phone calls I view this as a good thing. My patients will be discharged on medications they can afford and will take. Then we can spend our time in the office taking care of health problems instead of fixing something that shouldn’t have been broken to begin with. 


1. Medication Adherence: WHO Cares? Brown MD, Marie T. et al. Mayo Clin Proc. 2011 April; 86(4): 304–314. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068890/


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Medication Moments in Family Practice

Yes, that her “out” during
freshman orientation.

My younger daughter has a condition known as narcolepsy (she OK’d this post by the way). Because of it, she has a tendency to fall asleep any where and any time, but it is worse in the mid-afternoon. During college she was prescribed a medication called Provigil, which improved her ability to function in the real world, particularly in afternoon classes. Her classmates were a little disappointed at how well the medication worked as they could no longer tease her with drooling photographs taken during lectures. Due to the cost of the medication, she quit taking it while doing her present research job in Panama. Recently, she realized that her tendency to fall asleep in the middle of writing was interfering with her ability to finish her research paper. I’d heard that Provigil was now generic so I looked to see how much that would cost us, expecting some improvement in price. Nope it is still $26/pill if you pay without insurance (that is NOT a typo, with a prescription but no insurance coverage, thirty days of the drug will cost in excess of $788). WITH our Humana insurance, it would be a little more than $100/month, IF we could get a Prior Authorization on it. She bought it in Panama for $2 a pill. She did not need a prescription. I suggested that she stock up while she’s down there. Maybe she can get enough to last through graduate school.

Following that personal medication moment, I received a fax from RightSource, the prescription company owned by Humana. They wanted to know if a patient of mine who is taking a blood pressure drug called Bystolic was using insulin. Insulin, as you probably know, is a hormone important in diabetes and can be given in injectable form to diabetics. Bystolic is a type of blood pressure drug that can mask the symptoms of a low blood sugar in diabetics. The weird thing is, this patient is not a diabetic. Humana has yet to answer my request as to why they were asking me the question.

Vagifem

On Friday a patient came to me who is post-menopausal and having some vaginal dryness which is making intercourse uncomfortable. I suggested using a topical estrogen, specifically a drug named Vagifem. Many women prefer this form of topical because it is in a small pill that is much less messy than creams. Now here is where it gets weird. First of all, I could not tell the patient how much this prescription would cost her in the pharmacy because it is a “third tier” listed drug with Humana. She can look it up on line on the MyHumana site but I have no way of knowing. I do know it costs about $68/month if you don’t use insurance to buy it. There are no “generic” estrogen creams BUT Humana lists Premarin estrogen cream as second tier which typically is a $30-40 monthly copay. Here’s the kicker–if you buy Premarin cream without insurance it will cost you $150/tube (a tube will last anywhere from two to four months).

My medication frustrations this week were multi-fold–why do drugs cost so much more in the US than other countries (here’s a link to an interesting article in the New York Times that is old but still rings true regarding this question); why do I have to spend my time answering ludicrous questions for drug coverage companies in order to get my patients’ drugs refilled; and why isn’t there more transparency in medication costs for me and my patients?

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