Should doctors talk about the cost of drugs with their patients?

I first realized something was amiss when I picked up my prescriptions and the pharmacist explained that she could not fill the anti-malarial medications as prescribed: “Your medication plan only pays for 30 days of pills, and your prescription was for five pills.” The pharmacist continued: “Your PBM [that's an acronym for pharmacy benefits management company, the type of company that coordinates many peoples' medication coverage] only fills this medication for 30 days at a time. And 5 pills would last 35 days.”

Expert logician that I am, I countered with some math of my own: “Well four pills, taken weekly, only lasts 28 days. If they really want to give me 30 days of coverage, they need to give me a fifth pill.” I thought it was insane to pay a whole extra co-pay to get my fifth and last pill, a co-pay I’d have to pay for my two sons too since all three of us were traveling together.

But the pharmacist was unpersuaded: “Sorry, four pills is it. You’ll need another prescription for the last pill.”

Irked, I handed over my credit card and hastily signed the bill, too bothered by the conversation to look closely at the bottom line.

When I got home and told my wife Paula about the saga of the fifth pill, she calmly looked at the bill and asked me: “If you were so concerned about a $10 co-pay, why didn’t you notice that the antibiotic you were given cost almost $200?”

Huh?

I should give you some background to this story. A couple of weeks before my trip to the pharmacy, my wife and I had decided to take our sons to Belize for the holidays. She travels internationally for her job, so she was up to date on all of her immunizations and was well stocked with travel medications. But the boys and I had to scramble to get ready in time. We had to start our anti-malarial pills before departing, for instance, and also needed to get typhoid and hepatitis injections early enough for our immune systems to respond. So we went to our family physician, a kind and personal man who had taken care of my boys’ ailments over the past year. He looked up Belize in the CDC website and prescribed everything we needed. Among the medications was an antibiotic we could take if we developed traveler’s diarrhea. That was the prescription that set me back almost $200.

I spoke with the physician after my trip to the pharmacy, to explain that we needed new prescriptions for the anti-malarial medications. He apologized for the screw up. I told him it was no problem, but I did wonder about the price of the antibiotics: “Did you know how much those antibiotics cost?”

“No,” he said. “I had no idea.”

“Couldn’t we have settled on a less expensive antibiotic?”

“Well I mentioned the name of the pill when I prescribed it,” he replied in a courteous tone, “and you didn’t have any objection.”

Okay, a bit more explanation here. I was a patient in this particular scenario, but I am also a primary care physician. It is often awkward for people like me to seek care from other primary care physicians. I worry that other primary care physicians will defer to me. But I don’t like the idea of being my own doctor. As the old saying goes: “The doctor who cares for his own ailments has a fool for a patient.” In addition, I worry that my physicians leave things unsaid when communicating with me, because they assume I can fill in the blanks. As in: “If I mention that antibiotic and he says okay, it will be because he knows what the alternatives are and agrees that this choice is best.”

That assumption was as wrong as a walk through a Belizean jungle without mosquito repellant. Because, you see, I know almost nothing about travel medicine. In my 15 plus years practicing in the VA health system, no patient has ever come to me asking for travel medications.

To be clear, I didn’t end up with expensive antibiotics simply because my doctor thought I knew what I was getting. Instead, as I talked to him further, he tried to justify his prescription decision: “Peter,” he said to me when I told him the cost of my drug, “I got back from a third-world country recently and the antibiotic I took there left a metallic taste in my mouth for a week. I would gladly have paid $200 to avoid that fate.”

“Good for you,” I thought. “But wouldn’t it have been nice to find out whether I, your patient, wanted to spend $200 that way?”

In the last few decades, medical schools have been teaching us doctors to inform patients about their treatment alternatives, so our patients can pick the alternative that best fits with their individual values. Which raises the question I’d love your input on:

Should doctors take the time to figure out the cost of treatment alternatives and communicate such information to their patients?

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.

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  • http://profile.yahoo.com/CLC6F5DSYDDYGHET7WN6IPJ37I George

    It is not realistic for providers to know the cost of each drug they prescribe, but as a provider I have a general idea of what is on the $4 list and what is expensive.

    The cost of a prescription for an individual patient is hard to know because pharmacy prices vary and insurance companies cost to the insured’s vary a lot.

    I don’t mind phone calls from the patient (or, preferably the pharmacy since it saves a step) to see if there is a less expensive alternative.

  • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

    For us, this is a crucial part of patient counseling.

  • Anonymous

    This is yet another side-effect of the third party payor system – no one knows the price so negotiations are impossible. Such opacity prevents a free market from working in healthcare.

    • http://www.facebook.com/people/Roberta-Ghahremani/100000919815524 Roberta Ghahremani

      I totally agree with you on this.  Have you EVER encountered a physician who would offer more than one option on first advice, discussing the perceived advantages, both cost- and efficacy-wise vs the negatives?  No, and this is not only because they may not know, but they are under a time crunch to generate as much profit as they can….another upshot of our current dysfunctional system.  A discussion of this sort would use up precious time.

  • Anonymous

    I’ve had a similar experience of having a $120 antibiotic prescribed and to add insult to injury, it didn’t work. But a $7 medication did.

    It doesn’t seem too much to ask that the cost of the most commonly prescribed drugs be known. Or as another commenter mentioned, there are several national pharmacies that offer a range of generics for $4 – having that list handy could help.

    Wouldn’t be surprised if there are mobile phone aps that quickly help people find out local drug costs; there are websites that do.

    Doctors want their patients to take the medication. But many patients report they cannot afford the medication. So it makes sense to be sure that when prescribing to “fit patients’ values,” cost be a consideration as well. 

    Cost is just one of the 5 questions that could change health care. Here’s more: http://whatstherealcost.org/video.php?post=five-questions 

  • http://twitter.com/darbsnave darbsnave

     A drug rep from Cephalon came to see me. “Doctor,” he explained, “you should prescribe our Nuvigil instead of our Provigil. We brought out Nuvigil at half the price of Provigil. It’s $400/month for this stay-awake medicine instead of $800-1600/month for Provigil.” “Yes,” I said, “but you doubled the price of Provigil just before you brought out Nuvigil. You don’t want patients on Provigil, which will be generic soon, but want them on Nuvigil.”

  • http://twitter.com/HealthMedWatch Tom Farrell

    Agree with George: it’s unrealistic to believe that physicians will know the cost of thousands of medications on the market today. That’s the patient’s job.

  • Chris OhMD

    Docs should know at least the ballpark estimate of common drug costs. We live in a culture where doctors have no idea how much treatments cost and patients have no idea how much they will have to pay until they pick up the meds or get a bill for a procedure – this creates inefficiency at multiple levels. If I prescirbe an unnecessarily expensive drug, most likely I will have to spend extra time the next day talking to pt, pharm and switch to cheaper generic because patients are looking for cheap drugs (that’s just the trend these days after the recession). To pretend that doctors are not responsible for knowing treatment costs for patients is like living in a fantasy world. It is very easy to figure out costs. I frequent http://www.healthwarehouse.com and most docs have <10 drug repetoire of commonly used drugs.

  • Anonymous

    I also agree with George; we often have an idea whether a medication is expensive or inexpensive, but can’t memorize just HOW expensive each one is.  We count on the patients getting their sticker shock at the pharmacy counter and calling us about alternatives before they pay.  We can’t do anything if they complain after they have paid.

  • Sarah Wells

    Maybe you could just enjoy a trip to Sweden instead.   Jungles are overrated.

  • Anonymous

    If only it was possible for providers to even KNOW what drugs cost!  Costs to patients depend on a number of factors including the pharmacy at which the prescription is filled (can vary greatly in some cases, and slightly different drugs are on say, the walmart vs target low cost prescription list), insurance details (sometimes certain brand name drugs can actually be cheaper than generics based on managed care formularies).  Drug prices can also change significantly over time.  I try very hard to be conscious of cost and prescribe the cheapest appropriate drug, but I not infrequently make a choice that is not the right one for that particular patient from an economic perspective.  To some extent, the best thing we can do is keep lines of communication easily open between doctors’ offices, pharmacies, and patients, and encourage patients to call if the prescription seems insanely expensive or otherwise crazy.  Yes, it’s a hassle, I’ve been on both sides, but our system is so darned complicated that mistakes happen.  Remember that it is actually very unlikely that your provider actually wanted you to pay $250 for nasal spray…

  • Anonymous

    I think knowing the four dollar lists and taking note of a few older drugs that are likely cheap is good. Many drugs, wildly variable pricing.

    I would honestly encourage patients to print off a copy of their drug formulary a few times a year, as insurance companies tend to tweak their formularies more than once during the year. I keep tabs on mine and carry it with me to appointments if I’ll possibly be prescribed something. Saves a lot of headache. I also tend to say, “Give me the oldest drug possible unless the side effects are so horrific I’ll cry for mercy.” Gets a look or two since people still want what’s “modern,” but I’ve found this request to be helpful.

  • Gil Holmes

    Knowing the price of a drug before hand can be near impossible. Heck, even the $4 list isn’t always only $4 if you buy the drug with insurance. Coupons from drug reps that promise that no one will be charged more than $35 are just outright lies in my experience to the point that I disclaim it when I give them. ‘This says it will only be $35 but that depends on your insurance, your copay, your deductible, and probably other factors that neither I nor you know’. Now I do use predominantly generics but sometimes there just isn’t a generic appropriate for the particular situation and sometimes the generic itself is expensive.

  • Anonymous

    What may be more important than knowing the price of the drug is whether or not the patient can afford it. No matter how cheap the doctor thinks the medicine is, the patient may not be able to afford it. In my daily work I hear from people who are in this situation – can’t afford their drugs. 

    It’s unrealistic to expect doctors to know the cost of every drug they prescribe, but they should have a general idea of the costs.

  • http://profile.yahoo.com/ZHAQIRPFPZ6OR7NOADMJUKE4AU Pamela P

    Yes, doctors need to be aware of the costs.  I recently had an issue of something that I take everyday, it’s an OTC (over the counter) drug but my insurance covers it also, same pill, same strength.  My previous doctor rx’d it for me at the cost of $5 with insurance, my new doctor’s nurse said “you can buy that at the store”, I knew this already, had been buying it at the store for 3 years @ $27 a month!  When I see my new doctor for a 6 month check up that I don’t really think I need, you can be sure I will discuss this issue with him!

  • Anonymous

    Yes they should talk about it with the patients world wide.

  • corali cottagehaan

    It is a given that some people must pay the lowest possible price for their medications.  Thus, at some point in the process of obtaining a prescribed drug, the person should be able to choose the least expensive alternative.  If this choice isn’t possible at the pharmacy, then it must be done in the office of the physician.

  • http://twitter.com/gvanantwerp George Van Antwerp

    I think if you look at the work from Shrank, et al from several years ago it shows that physicians don’t know the cost of drugs and don’t see it as their responsibility.  They see it as the responsibility of the pharmacist. 

    As mentioned below, there is definitely a shift to consumers being more aware of this using mobile technology from PBMs, independent tools like GoodRx, and employer sponsored programs like Change Healthcare. 

    Additionally, you have more and more drugs that now have copay cards or coupons available to address the consumer out-of-pocket. 

    With over 10,000 drugs on the market and numerous plan designs, there is no way for anyone (without technology) to know the cost of drugs.  A reasonable expectation might be to understand the relative cost of the top 20-50 drugs that a physician typically prescribes. 

  • http://twitter.com/advocacyrss AdvocacyRSS

    Great question.
    Yes and No.  It should be a collaborative effort on behalf of patient and physician – yet, patients need to also learn to be advocates for themselves.  I encourage this with caregivers of children with rare disease.  We need to take the time to understand the medications we are taking, the benefits and treatment options available aside from those medications as well.  During that communication process, the obvious would ensue….a review of all available medications for said diagnosis.

  • Anonymous

    For many of the illnesses for which I write prescriptions, I can choose from a variety of  equally appropriate medications.  After being shocked by the cost of even some generic medications, I now tell parents that if I ever prescribe a medicine that is not covered by insurance or is very costly, do not assume that I want that and only that medication no matter what the cost. I ask them to call the office so that I can pick a more affordable (and equally effective) substitute.

  • http://twitter.com/lumi86 Jennie Yoon

    I believe that the responsibility lies on physician and pharmacist equally. Physician and pharmacist should work together to figure out the best option possible for the patient. I work in a pharmacy and encounter so many prescriptions that write for drugs that are not cost-realistic on the patient. We don’t blame the physician since it is the pharmacist’s job to know all the drug options available out there and advise patient and physician regarding the information. I just wish that the patient’s PCP would respond to pharmacy’s call in a reasonable amount of time though. Too many times, the patient cannot receive the alternate therapy on the day they need it. Is there a solution for this? I don’t know, but I hope for a change in the future.