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Yes, you really can put a price on health

Unlike Israelis, Americans often pay astronomical amounts of money for medicines that can save their lives

Imagine the following scenario. A patient goes to see a doctor about a serious condition and is fully and professionally assessed. After careful thought, the doctor writes a prescription for a medication that will definitely treat the immediate disease. The patient leaves the doctor’s office, greatly satisfied, and makes his/her way to the pharmacy. The pharmacist accepts the prescription, hands the medication to the patient, and then asks for $500 for one week’s supply.

The patient is dumbfounded. He/she simply cannot afford such a sum of money for more than one or two weeks. The patient calls back the doctor’s office and books another appointment, but this is only available in another month. After a month, and $2000 in medication expenses, the patient sits once again with the medical specialist and now receives a prescription for a similar medication, which is an accepted alternative to the first. The patient looks up at the doctor and asks “how much will this cost”. The doctor in turn looks surprised and admits that he has no idea. He even makes a joke that if he wanted to deal with prices of medical care, he would have become an accountant.

I don’t think anyone should be surprised to hear that this is a real life scenario that recurs day after day, at least in the United States. Here in Israel, the HMOs are much more aware of medication cost. Also any doctor working with an HMO, is also working with their computer system which includes a consideration of cost in their medication list. It is also much easier to find out how much medications cost here in Israel.

How do doctors decide which version of the medication to prescribe, when more than one option exists? This is an excellent question and one that is critical to the pharmaceutical industry. Why is it critical? Well, there are multiple medications that can be used for a disease like high blood pressure. Some of these medications are extremely cheap, costing pennies a pill. The newest version of medications for high blood pressure, may cost many dollars per pill. Which do you imagine that the pharmaceutical company would prefer to be prescribed by the physician?

The vast majority of doctors gain nothing from prescribing higher cost medications. So why would a doctor choose a more expensive option over another? Well, believe it or not, it may simply have to do with good advertising. When a representative of the pharmaceutical company presents to a physician, he or she is often well-dressed, well groomed and ready with a unit of medical knowledge that will justify the replacement of previous high blood pressure treatments with this newest [most expensive] option.

I am sad to inform those who did not know, that many physicians [for a whole variety of reasons] do not read medical updates as often as they should. In other words, many doctors’ most updated knowledge comes from such pharmaceutical representatives and various lectures that may be sponsored by pharmaceutical companies. There is definitely a trend now to try and limit such influence on physicians by pharmaceutical companies. But it is always hard to truly eliminate influence on doctors, so long as there is significant money to be made by those who sell the medications.

I personally have dealt with such representatives many times in the past. After respectfully listening to their presentation, I would ask the question that they were often not prepared for. Quite simply, I asked them how much their medication cost relative to what I was presently using. Because all Israeli citizens are covered by one of four national HMOs, the price that a patient pays is usually a reduced price due to the subsidy from the HMOs. So it may be that the cost of an old treatment versus a new treatment is not that different because of the HMO participation in the payment to the pharmaceutical company.

When I asked the representative what was the true original price of the new medication, she asked me why this was pertinent. I said to her, that whether or not an HMO subsidizes the cost of the medication, ultimately it is our tax money that is paying for this new medication. Therefore, if the true price of the new treatment was significantly higher than that of the older treatment, and the effects of the new treatment were not dramatically better than the old treatment, then my tendency would be to continue to prescribe the old treatment.

It took her approximately 15 minutes and two phone calls to discover that the true cost of the new treatment was in fact many dollars per pill, versus pennies per pill for the older treatment. I looked at her with an expression that clearly indicated that I was not interested in her new pill. And she looked back at me with an expression that made it clear that she understood why. Does that mean that from now on she will mention the difference in true cost between the older and newer treatment? I think it is likely she will not, considering that part of her salary is based on commission.

Here is one more example of how EMR’s can drastically reduce the cost of medical care. When doctors complain that prescribing is more complicated than before [when all they had to do was scratch some symbols on a piece of paper], the doctors are correct. They are correct because prescribing a medication should NOT be simple. Any time a doctor prescribes a new treatment, he or she should take the time to make sure that it is the most cost-effective option. The doctors should review all the possible side effects and relay these to the patient. The doctor should take into account that the patient might have poor eye sight and easily confuse one of the new medications with another one that the patient is already taking. I can promise you that there are very few physicians who really take the time to do all of these things.

On the other hand, a computerized EMR can easily do all of these tasks within a second. The EMR can check for a whole range of possible problems with the present prescription and even offer legitimate alternatives. The result of all of this checking by the computer is that the doctor only need click a different name than the one initially chosen.

The doctor may complain that he or she has been robbed of their freedom in choosing what they feel is best for their patient. There is a computerized solution for this as well. The doctor can choose any alternative he or she wants. The doctor need only explain in significant detail why the alternative is being chosen. A senior member of the HMO will review this explanation, and if it is found to be acceptable, will give clearance. If on the other hand, the explanation is lacking, the doctor will have two options: give a better explanation or pay the difference. I think it is unlikely that doctors will choose to give an alternative in this reality.

A great deal has been said about the potential negatives of various EMR’s. These negatives are often expressed by physicians. But the physicians themselves may not be the most objective when it comes to truly evaluating the benefits of the EMR’s. My personal belief that it is only a matter of time before the benefits of EMR’s will be so widely recognized, that no one would even dare suggest going back to pen and paper.

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.
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