And now we
come to the second part of our story: the two-tiered system of mandated
allowable prescription drugs. Actually this is a multi-tiered system as each
insurer is legally able to create its own list of approved drugs (two tiered
refers to drugs the more wealthy can purchase through their insured
prescription drug plans vs less wealthy people who have more restrictive plans).
What all of these approved lists have in common is cost control, with minimal
regard for patient care. What all of these approved lists have in common is
disrespect for doctor prescribing decisions. What all of these systems
incorporate is an appreciation that young doctors tend to prescribe more
costly, newer drugs most often determined by an educational system that
indoctrinates doctors-in-training to believe that newer is better. What all of
these systems incorporate is a realization that patients come to doctors with a
belief that what is newer is better. “Is the new medicine stronger than the old
one?” asked the patient. “The new drug is different
from the old drug and stronger may not be better” I replied. “Just as eating
one fruit might satisfy hunger better than another without being stronger, its
advantage lies in its being different.”
But I
digress… . Patients now have two quandaries when obtaining prescribed drugs.
The first is the limitation of allowed drugs on their prescriptions plan. Not
infrequently an excluded drug may have quickened recovery from a disease
process with fewer side effects. This is the essence of the battle between
Gilead and Abbvie as Gilead has the more efficacious drug with the least side
effects for treating hepatitis C but Abbvie has a cost advantage. The second is
the co-pay which is part of patient prescription drug plans. Patients are
confused between what their co-pay mandates them to pay and the cost of the
drug. In the Medicare population this frequently results in patients being told
by pharmacists what the list price of the drug is as a preface to what they
owe. The natural response by the patient is anger that the drug is expensive
even though the patient cost is much lower than the list price.
I judge that
it is not unlikely that insurers have contracts with pharmacies and/or with
pharmaceutical companies to limit the cost of specified drugs so that
communicating the list price of a drug is not relevant to the prescription in
question. In this era of confrontation and misinformation each participant: the
patient, the pharmacist, and the pharmaceutical company have an agenda which
ultimately inflames public perception.
Two other
variables alter the public’s ability to obtain cost-effective medication. The
first is the sheer amount of paper-work necessary to complete a prescription
for a slew of medications which are proven efficacious but which cost more than
the majority of medications. The irony here is that the cost of the medicine
may be a fraction of the cost of treating with an inferior set of medications.
An excellent example is hepatitis C which can be treated at a cost of 85,000.00
vs cost of lifetime care of a patient at more than 500,000.00. Similar examples
can be given for psoriasis and arthritis. The second variable is the
obfuscation of cost of medications by pharmaceutical companies that provide
coupons for patients which limit the patient’s co-pay. The coupons fail to
state that the purpose is to increase sales at the expense of insurers who must
pay the balance owed on a more expensive drug.
In summary
there are no heroes in these games, only selfish participants. Patients, doctors,
insurers, pharmacies, and pharmaceutical companies each have their own
self-interests. Yet it is axiomatic that from overcoming obstacles comes
innovation. This is no less true in the medical therapeutic field. Next blog:
inexpensive innovations in medical therapy, or, Back to the Future
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