Featured Post

How Much is that Pill In the Window?

The pharma business helps people overcome illness and suffering, but its stil a business
Illustrative photo of pharmaceutical pills (Abed Rahim Khatib/Flash90)
Illustrative photo of pharmaceutical pills (Abed Rahim Khatib/Flash90)

I am well aware of the fact that I have very often said that one must have evidence to support any medical claim. In the following article, the authors effectively note that it is important to consider cost of medication when prescribing. The article relates to patients’ adherence to statins, which are very important medications in the management of high cholesterol. Statins have been shown to have a very positive effect on the health of many higher risk patients. Therefore, increasing patient adherence once the statins have been prescribed, is a very desirable endpoint.

What irks me is that you really don’t need a study to prove that cost affects decision-making. Even in matters of health, when one would assume that most people pay much less heed to cost, the simple fact is that there have already been endless discussions related to cost and medical care. The entire issue of Obamacare ultimately centers around reducing cost of [and thus hopefully increasing accessibility to] healthcare. Therefore, when I read the results of a study that unquestionably took time, resources and money to complete, that concludes that cost affects adherence, I become disappointed.

I become disappointed because it clearly indicates that doctors do not pay sufficient attention to such a basic and critical point. Perhaps the cost of admission and treatment is beyond the ability of the average doctor to affect. But doctors prescribe medications, often expensive medications, to their patients on a daily basis. It is very likely that minimal consideration of this issue, could dramatically improve the health of a nation. More so, paying attention to cost could relieve a tremendous amount of financial pressure on millions of people who may feel that they must take only the commercial version (versus the generic version) of the medication. In other words, when doctors say that they truly want to help their patients, taking the time to consider the cost of medication could be one of the most helpful things that any doctor can do.

I have spoken before of visits to me by pharmaceutical company representatives who make strong arguments for the use of new medications that their company has released. Doctors are unquestionably influenced by these representatives, and in fact, more and more countries are fighting this form of advertising [which is exactly what this is]. From my own, admittedly limited, experience with such representatives, the true cost of these medications is rarely, actually never, raised. I literally have had to ask multiple times, during the same interaction, for the true cost  of the medication, before receiving an answer.

Often, the representative was not even able to tell me the cost. Instead, the representative would explain how various insurance plans cover variable amounts of the cost, and thus help the patient to purchase the medication. But whether an insurance plan does or does not cover part of the cost of the medication, someone somewhere is paying the full price. And when that price is paid by a government insurance plan, at some point, it will be the entire country that pays for those medications via taxes.

More so, representatives will often speak of the effects of a medication relative to no treatment. Let me use the case of managing high blood pressure as a classic example of the need to ask the appropriate questions. I have had representatives tell me of the excellent effect that a new medication has on high blood pressure. When I ask how this medication compares to existing high blood pressure medications, I would occasionally not receive an answer. Amongst the packet of research studies that the representative would hand me, there would be no comparison between the new medication and existing medications.

In cases where comparisons between new and old were given to me, I would then ask for the total cost [to insurance and patient] of the new medication. In one case, it took the representative over half an hour and multiple phone calls to retrieve this information from her superiors. I was informed that the new medication would cost three dollars a day. I looked at the representative and asked her, “some excellent existing medications cost pennies a day. How do I justify paying three dollars a day for what appears to be a minimal additional benefit?”. In those cases where I posed this question, I almost felt sorry for the representative. It was clear that during their training, representatives were never presented with a scenario where a doctor would ask such a question. If most doctors, or even some doctors, asked these questions, the representatives would be prepared to answer. In my experience, none of them were prepared for, or able to provide me, with any type of reasonable answer.

I personally believe that one of the key features that an EMR [electronic medical record] should have, is a listing of the costs of treatments. By the way, I would include in this every test and treatment. For example, if a doctor is trying to decide whether to order an ultrasound versus an MRI for a specific condition, the fact that the ultrasound costs much less may appropriately skew the doctor’s decision. An ultrasound, like an MRI, is a noninvasive test. However, it is often easier and faster to get an appointment for an ultrasound. If an ultrasound is an acceptable first line of testing, then there is no reason that it should be skipped. And if the ultrasound answers the question of the doctor, then the entire healthcare system has been spared unnecessary stress on resources.

I could easily see this as a true benefit of a program like Obamacare. All pharmaceutical and testing companies should have to provide a price list to clients. The way to do this would be to post the list online [as it should be made public knowledge in any case]. Companies that sell and support EMRs could then import these price lists into their software. From a technical point of view, it is possible to automate this process so that whenever there is a new test or medication, or new price for a test or medication, the update to the EMR happens almost immediately.

This really is a case of win-win for patients, physicians, insurance companies and EMR companies. When such information is available, leading to a reduction in healthcare costs, patients will become less stressed and will reflect that in their interactions with the healthcare professionals that care for them. Admittedly, the pharmaceutical and testing companies will be under increased competitive pressure, to keep their prices as low as possible. I personally have no problem with this fact.

I hope that the medical community agrees that there is sufficient evidence from the literature, to support the claim that lower-cost leads to improved health care outcomes. I now hope that this will spur a change in physician behavior and sharing of cost information, so that patients benefit to the maximum possible. EMR systems can make sure that this information is readily available to the physicians and even to the patients. I hope that the initiative will be taken to make these changes.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
Related Topics
Related Posts