Healthy Skepticism Library item: 11952

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: news

Cassels A.
MDs ignorant of drug costs
Common Ground 2007 Nov
http://commonground.ca/iss/196/cg196_cassels.shtml

Full text:

Imagine seeing your doctor for a simple medical problem, like a bit of heartburn. It’s been bothering you a lot and you’ve tried a few things, but there’s not much you can do to relieve the burning in your gut.

She checks you over, asks a few questions and then diagnoses GERD (gastroesophageal reflux disease). She tells you there are a number of lifestyle things you should try to help stop that stomach acid from rising up into your esophagus, but you tell her you’ve already tried those things and just want a pill. She pulls out the prescription pad, and with pen poised, pauses to ask, “Do you have a drug plan?”

“Uh, yes,” you answer. “We’ve got Blue Cross through my spouse’s employment.”

“Ok, then. I’m going to prescribe you this,” and she scribbles something on the prescription pad and passes it to you.

Your curiosity overwhelms you. “Why should the drug plan thing matter?” you stammer, suddenly feeling the same way you did at the dentist’s office when the receptionist asked if you were covered by an extended health plan.
Your doctor responds, “Well, it actually doesn’t really matter. The drugs in this class all do the same thing. But if you’re on a drug plan, I can give you the more expensive one that Pharmacare won’t pay for,” she says, looking satisfied, silently recalling a bit of advice she got from a colleague once: prescribing the more expensive drug delivers a bigger placebo effect. It’s one of many ways to show your patient how much you care.

“But won’t a cheaper one work?” you ask.

“Yeah, they’re all about the same, but some people like the newer ones.”

“Ok, whatever,” you say, as you head for the pharmacy, reflecting on what just happened. If there is a range of equally effective drugs which differ only in price, is it not somewhat irrational to buy the more expensive one?

Before you leap to call this a drug company conspiracy, you need to know that this story is simply not that simple.
While it certainly seems a waste if you are prescribed a more expensive drug when a cheaper one would work just as well, the problem is that most doctors don’t know much about comparative drug prices. They openly admit it. They don’t even do that well in assessing comparative effectiveness. Not because they’re uninformed, but because the head-to-head studies needed to compare one drug to another are simply not done.

Why? Well, most new drugs are compared against placebo, not against other drugs already on the market. When someone comes along and says this newer drug is “better” than what the doc is currently prescribing, that person is usually sucking wind. Chances are the study to prove the “better than” claim hasn’t been done and will likely never be done. And in terms of drug prices, if physicians don’t know the comparative prices of drugs, it’s because that knowledge isn’t a huge priority.

With the escalating costs of drugs continuing to eat a bigger share of our personal income and forcing our public and private drug plans to scale back benefits, this is no laughing matter. You might openly gloat that your deluxe, extended health plan covers the Cadillac of pills, however, I can safely assure you that the cost of that ride is coming out of your wallet one way or another.

You might consider yourself lucky that the doctor actually asked you about your coverage and even considered if you could afford it. In reality, patients who face buying prescriptions priced beyond their means are less likely to fill their script, a more severe problem in the US where prices of brand name drugs are much higher than here. And if you don’t go to the pharmacy, or leave the pharmacy without your script, or worse, refuse to take the drug once you’ve bought it, you are exhibiting “non-compliant” behaviour, a nice term that means you’re a bad patient.

Consider this non-compliant scenario: A 30-year-old construction worker goes to the doctor coughing and wheezing, complaining about shortness of breath. He’s having an episode of asthma and the doctor prescribes a drug that, to the patient’s horror at the pharmacy counter, costs $160. Without a drug plan, and no room in his budget for this extra expense, he walks empty-handed out of the pharmacy, back to the jobsite still wheezing and coughing. Later that afternoon, his airway getting tighter and tighter, he staggers and collapses, unable to breathe. His workmates call 911, but it’s too late and he dies on his way to the emergency room.

Dead – for the lack of an effective drug that could have cost him only $20.

This sort of needless and senseless end is what I call “Death by Sticker Shock” where the system we’ve got in place avoids making patient-specific affordability an essential part of the prescribing equation. And people do actually die because of it.

A lot of things could have helped to prevent that death: better asthma education, avoiding the asthma triggers, (wearing a dust mask at the worksite), learning about the range of available treatments and their respective costs from his doctor, and so on. An astute pharmacist could have identified a potential problem – coughing patient refusing to pay for an asthma drug – and steered the man towards a more affordable treatment. None of these things happened.

But let’s not be overly dramatic here. For most conditions, being “non-compliant” is not serious. But in some conditions, essential or “emergency” scripts such as an epinephrine (for acute allergic reactions due to anaphylaxis), salbutamol (for acute asthma attacks), insulin (for insulin-dependent diabetics) and a host of others, not taking the treatment can be a death sentence.

How often does the cost barrier prevent someone from getting the drug they need and cause that person’s death? We don’t know. What we do know, and some call this is a serious indictment of the practice of medicine, is that many doctors have a very poor understanding of pharmaceutical costs. A recent meta-analysis of 24 studies examining physician knowledge of drug costs found that physicians have a very low accuracy in predicting drug costs; only about a third could estimate within 20 to 25 percent of the drug’s true cost. Less than half could estimate a drug’s price by “… any definition of cost accuracy.”

This study showed something very interesting. Rather than denying the importance of drug costs, doctors want cost information and they believe it would improve their prescribing. They generally agree that drug cost info is hardly ever easily accessible.
So who should inform them? The fact that many of our physicians cannot appreciate the large difference in cost between inexpensive and expensive drugs is not only a medical problem; it is also a public policy problem. The drug companies aren’t generally interested in marketing their drugs on price (with some exceptions) so it really is up to governments and insurers to keep physicians informed of drug costs. And up to now, we aren’t doing enough to prevent the problems associated with pharmaceutical sticker shock.

And that’s sad because as the population gets older and as the need for optimizing health care expenditures increases, there is a vital need for physicians to think about how they can be better and more cost-effective prescribers. They might have a strong tendency to want to prescribe you the newest, latest and greatest drug for your aches or pains and you walk out the door with a script for the newest drug out there, like Celebrex, Bextra, Prexige or Vioxx. No one needs reminding that, of these four newest anti-inflammatory drugs, only one (Celebrex) remains on the market, despite its warning of cardiac risks. The others have been removed because of intolerable, sometimes fatal adverse effects.

As a potential patient how can you work to keep your drug costs affordable? Consider the following:

Alternatives: Any new condition usually has a host of non-drug things you need to try first. You’ve got heartburn? Take a close look at your diet and actually try to do the lifestyle things they recommend. Ask if there is a safer herbal treatment that might help.

Benefits and harms: If the doc is offering you a new drug, you need to know how well it stacks up against its competitors (drugs already on the market) or other non-drug treatments. With rare exceptions, any drug newer than five-years-old should be treated with suspicion because we simply don’t know enough about how it works in the real world. Older drugs may not be safer than newer ones, but physicians have more experience with older drugs and they can use them with more judgement and discernment. A newer drug may have some advantages, such as being more convenient (once a day instead of twice), but you have to decide if that difference is important and worth paying extra for.

Coverage: If there is a range of equally-effective treatments, ask your doctor for the most cost-effective of those.
There is no use wasting your or your employer or insurer’s money. If you are asked if you have a drug plan, you might want to find out if that is a relevant question in your situation.

It’s true that drug costs can give you a pain in the gut, but knowing comparative drug prices can go a long way to help relieve that heartburn. It may even prevent death by sticker shock.
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Alan Cassels is a drug policy researcher at the University of Victoria. He hopes to get a big grant someday from a philanthropist to start up the “Institute of Cost-Effective Prescribing” and work to make everyone’s prescription drug-taking behaviour more rational, and life-saving drugs more accessible.