Free Medicine???

I mentioned in my last post that there is an assumption that health care is expensive. In order to challenge that assumption, I began to specifically list elements that are necessarily costly and those that might have wiggle room. Getting open heart surgery is going to be somewhat expensive no matter how lean the ship is run. But open heart surgeries aren't the care that's breaking the collective bank. It could be argued, however, that the cost of medication is one of the deal breakers.

When I was in residency, the community clinic nearest me stocked basic antibiotics and dispensed them under their sliding fee schedule. This meant that many patients got their medicine for free. Stock bottles of amoxicillin, Bactrim, tetracycline, and others sat in the med room and providers dispensed the medicine directly under some specific guidelines and policies. Though this still occurs, regulation and standardization makes this a little more difficult. Many free clinics, however, do have associated pharmacies that offer very inexpensive or free medication.

Walmart made a huge splash with their $4 medicine program, and so many pharmacies have followed suit that extremely low cost, old generics have become a norm. Schnuck's offers many of the same antibiotics my community clinic stocked for free. (The assumption being that they easily make up their cost when you buy a 20 ounce soda on the way out.) As a pinko hippy, I'm not a big fan of Walmart, but one has to wonder how much this move has fueled the decrease in national spending on prescription drugs.

http://www.phrma.org/catalyst/retail-prescription-drug-spending-hits-lowest-growth-rate-over-50-years

Other factors such the economy, increased regulation of pharmaceutical marketing to physicians, and the lack of new "blockbuster" drugs are major players in this slowdown. However, over several years of writing prescriptions in the $4 era, I have found myself saying "Yes patent drug X is better than cheap generic Y. It's been proven about 10% better." Out of pocket costs for typical branded drugs are $80-120 a month and even patients with good commercial insurance often have $25-50 copays. The math is not difficult.

The $4 drug plan began in 2006, and the economic downturn not long after. In any case, the state of the economy of prescription drugs is vastly different that in 2005 when I moved to this practice. However, the old version of "free medicine" still inhabits almost every doctor's office - samples. Samples are of course a method of advertising. The only medications sampled are newer, on-patent products and the idea is that a patient could get their first month of a drug and if it is well tolerated, they could get a prescription after that. However, at least half of the samples are used to supply patients who would not have been able to afford their medication otherwise. The problem comes when there are not enough samples and a patient then must try to fill a significantly more expensive medication. And, by force of habit, a physician tends to use familiar medications. If a sample is readily available, it is more likely to be written on a prescription. Even today, some providers routinely prescribe patented medications that are at best equivalent to cheap generics.

There are some patented drugs that have no generic substitute. Different pharmacies charge wildly different prices for generic medications. And though generics are quite reliable, different companies' products do not always interchange seamlessly. This is notoriously true for thyroid replacement. Generics are not perfect. But for almost every single common condition, there are options.

No one should go untreated because of drug cost in 2012. Prescription assistance programs through the drug companies themselves provide enormous quantities of medication to low-income patients. Many Community Clinics are supported by a 340b grant which greatly discounts medications for their patients.

The problem is not solved by any means. In a recent trip to Walgreen's I was given three different prices for a course of amoxicillin ranging from $30 to $11. This is a medication that is on almost every $4 list and is probably the most common free antibiotic. You still have to be a very savvy consumer to maximize the system. There is still a LOT of profiteering in the pharmaceutical industry. I hope to get a chance to explore how things could be improved in future blogs.