Two of the biggest -selling prescriptions of all time, Plavix, an anti-platelet medication, and Lipitor, a cholesterol lowering medicine, have been available in generic form since May, 2012 and November, 2011, respectively. However, most retail pharmacies are still charging patients $100-$200 monthly for these medications. Why? And what does this market oddity say about our chances of lowering healthcare costs in the United States?

Patients are used to paying a high price for branded medications, and pharmacies know this. So when a new generic becomes available, many pharmacies discount the medication, but only by a small fraction as little as 10- 15%, However, the patient buying the prescription sees the new generic medication is somewhat cheaper and appreciates paying a little less for it. Over the course of a year or two, the price at the pharmacy retailer falls little by little. Eventually the generic medication stabilizes at a much lower price- as low as a tenth of the original, non-generic price. Meanwhile, the patient never realizes that they have been paying a very steep mark-up that constitutes as much as 15 times the wholesale price.

How did I come to realize this? Because for nearly four years I have run a cost- comparison web site for healthcare called LesliesList.org that serves the Chicago and Dallas/Fort Worth communities, and will become available in New York City by the end of this year.

Consider the example of anastrozole, a generic breast-cancer drug whose brand name is Arimidex. When a drug enters the generic market it can be produced by a wide array of manufacturers, usually within 6 months. The wholesale prices of these generics are subject to normal market forces and drop dramatically—but these cost savings are initially enjoyed by the major pharmacy retail drug purchasers and pharmacy benefit managers or PBMs, who are responsible for negotiating drug prices for insurance companies. But not by you and me. A few months after going generic in August 2010, the branded version of anastrozole, was selling for more than $400 for a month’s supply. The generic form was sold for $361 at CVS, $360 at Walgreens and about $340 at Walmart and Target. Sounds like a bargain, right?

Actually it was not. You might be interested to know that Costco has a well-publicized pricing strategy of charging the wholesale price plus a standardized 14% mark-up on everything it sells, including prescriptions. So how much was Costco charging at the time for this life-saving cancer drug? $27 per month. So we can deduce that the wholesale price at that time would have been around $24, which means that the major retail pharmacies were charging quite a hefty mark-up.

Why bring this up now? Because the generics of two of the all-time biggest-selling prescriptions, atorvastatin (Lipitor) and clopidogrel (Plavix), are at roughlythe same point in their pricing cycle as anastrozole was in 2010. What are their retail prices? From January 2013 through March 2013, thirty tabs sell for:

Atorvastatin (Lipitor) 20 mg
Costco- $17
Walgreens- $153
Target- $144
CVS- $148

Clopidogrel (Plavix) 75 mg
Costco- $14
Walgreens- $180
Target- $158
CVS- $173.

This table shows that for both atorvastatin and clopidogrel, the major retail pharmacy chains have been charging their cash-paying customers more than 10 x the presumed wholesale price. Pharmacy Times reports that in the United States in 2010 almost 46 million prescriptions were written for atorvastatin (as Lipitor), and 30 million for clopidogrel (as Plavix). Collectively, American patients who pay out –of-pocket for prescriptions could be saving billions of dollars annually on these two medications alone. But patients first must become aware that these wide pricing discrepancies exist. Most physicians don’t know. And governments do little to gather and publish prices.

Healthcare pricing is not transparent and the prices are not regulated in any meaningful way. Why is this? How does this make sense in a country where healthcare costs are the biggest strain on a struggling economy? Comparison shopping for healthcare must be made easier for Americans.

Leslie Ramirez, MD
Executive Director LesliesList.org
Clinical Faculty, Northwestern University Medical School

Walgreens: Tru Track Glucometer -$16 for the starter kit; testing strips $30 for a box of 100 strips.

Target: Up and Up Glucometer – $10 for the starter kit; testing strips $20 for a box of 50 strips.

Wal-Mart: ReliOn Glucometer- $9 for the starter kit, testing strips $36 for a box of 100 strips

Leslie

by Arvin Akhaven, Northwestern University Medical School, Second Year Medical Student

Doctors are already busy, but do they need to do more in a day? If you think a physician’s job is to take the best possible care of patients, then the answer is a resounding yes. But additional responsibilities do not necessarily mean more work—they just require different training.

It doesn’t take unique insight to understand that doctors, in many ways, act as social workers. They help patients schedule follow-up appointments, aid in translating jargon for the medically illiterate, substitute generic medications to curb the cost of prescription drugs, maintain close relationships with patients and their families or caretakers, and at least try to make sure that the patients can procure the necessary care or medications they need until the next visit.

Even so, the extent of social care that physicians provide sometimes seems to fall short. Some patients, after all of that hard work, still do not take their medications or follow up with their health appointments. According to a 2010 analysis of nearly two hundred thousand electronic prescriptions (Fischer et al.), up to 20 or 30% of prescriptions in the United States go unfilled. In some cases, the reasons for this are straightforward—maybe the patient just cannot afford the drug. Communication isn’t always frank or direct. A doctor may ask if the cost of a drug is prohibitive to a patient, but the patient may be too ashamed to admit that they cannot afford it. I have heard countless stories of patients splitting pills into twos or threes, or taking a one-a-day medication every three days, in order to make the bottle last longer. In other cases, medical illiteracy plays a part—where should a patient go to find the right medications at the right price, and is it possible to substitute a generic for the real thing?

In most inpatient settings, social workers are available to physicians to spearhead the effort to provide adequate social care to patients. Most physicians and hospital staff highly value what social workers bring to the table because they save everyone time and effort and help to provide better, more focused care to patients.

But social workers are not the final answer to all social care questions. Physician contact with social workers is not always as extensive as it should be. What’s more, when a patient leaves the medical center, the social worker’s obligation to or access to the patient is gone (they are, after all, paid to provide social care to patients while they are at the hospital). Further complicating matters is that margins are so razor thin at many private practices that it is very difficult to hire social workers (never mind that at practices with thirty-plus physicians, a one thousand dollar payment cut per year per doctor would be enough to hire a social worker to take care of the group’s sickest patients—that is a separate issue). Indeed, according to a 2008 membership workforce study by the National Association of Social Workers, private for-profit groups accounted for less than 25% of all health social worker employment (another 55% is employed by private non-profit groups and the remainder by the government). In contrast, the percentage of physicians in private practice as opposed to hospital employment varies depending on the source, but seems be hovering around 50%. Finally, medical social work does not seem to be structured to cater to the sickest patients, on a matter of principle, even though this “hot-spotting” strategy might prove to be effective in the future.

Doctors must therefore be trained to be better social workers. As is, most of the training is on the job. Training from experience is necessary, and it is how most physicians learn how to provide social care to their patients. But physicians should get more social care training and resources than those provided “on the fly”—as several physicians put it. Comprehensive medication and pharmacy cost databases (like the one provided for Chicago residents by LesliesList.org) need to be provided for physicians. Students and young doctors need to be taught how to use these databases while they are being trained—in medical school and residency. Currently, these databases are scarce, and we learn how to use them, again, “on the fly”.

If we are telling patients to get a drug or procedure, we are doing them a grave disservice if we do not help them by letting them know how to get it and where to get it cheaper. A physician is the patient’s advocate. Focused social care training efforts will go a long way toward making sure that patients get the best advocacy possible, and they might not take a significant set of resources to implement.

Just as the basics of medicine are taught in the classroom before actual medicine is learned on the wards, the basics of medical social care should be provided in a concentrated way for physicians to build off of as they begin to see patients. Training physicians on social care should be a more focused and organized effort.

Unilab, Inc in Oak Park

418 North Austin #2A, Oak Park, IL 60302    Tele: 708-848-1556

Hours: M,W,F 9am-1pm, Tu 10am- 7pm, Thur 12pm- 7pm, Sat 12pm-4pm

Chemistry panel- 14: $18 (average price: $29- 46)

Complete blood count: : $10 (average price: $29- 37)

Lipid profile: $15 (average price: $29-93)

TSH: $20 (average price: $36- 96)

Free T4: $15 (average price not available)

Urinanalysis: $10 (average price: $28- 36)

Vitamin D- 25 OH: $45 (average price: $60- 220)

PLEASE NOTE: There is a $10 additional fee to draw the blood.

Choose the best answer:

A. The doctor doesn’t bring it up.
B. Patients are too embarassed to say cost is a concern.
C. Patients assume docs can’t do anything to address the cost.
D. Doctors don’t have sufficient knowledge to discuss costs.
E. All of the above

Correct answer: E

Doctors don’t bring up the cost of prescriptions or testing with their patients.

In a study from the Archives of  Internal Medicine, one out of three chronically ill patients surveyed reported that their doctor never brought up the issue of cost. Of these respondents, almost half of them reported that they were too embarrased to bring up the matter of cost with their docs. And over half believed there was nothing their doc could do to affect the cost of the prescribed medicines and tests.

An earlier study from Archives of Family Medicine quizzed docs on the price of 50 commonly prescribed medications. No surprise — only 23% of the family medicine docs in the survey correctly identified the prices. The prices of branded (non-generic) medicine were underestimated 90% of the time. Generic prices were overestimated 90% of the time.

So why does it matter? Because when patients can’t afford what we docs prescribe, they go without or they take medicine inappropriately, such as taking half doses to make the medicine last longer. And they go without screening and diagnostic tests. And this is dangerous. And counterproductive. And a big fat waste of our collective healthcare resources.

We docs need to open our mouths and start the dialogue about individual healthcare costs with our patients. As a doc, if we don’t feel comfortable about our knowledge of what stuff costs (and 3/4 of us aren’t) then we need to educate ourselves. Go to LesliesList.org and see what medicines and testing price ranges are. Better still — have your staff run down prices in your area of the tests and medicines you commonly prescribe.

Is it time consuming and a pain? You bet. But we need to do it to make sure we are practicing effective medicine.

Most of the American public doesn’t know that different pharmacies can and do charge drastically different prices for their prescription drugs. Does that surprise you?  It sure surprised me when I found this out a few months ago in my medical school class.

I consider myself well educated. I’m a college graduate and in the throes of professional school—in healthcare nonetheless. I have an open mind and I read quite a bit. But I still wouldn’t have guessed that Coumadin would cost my uninsured father in Texas $15 for thirty pills at CVS, but only $4 for the same number of tablets at Walmart (I can actually vouch for this number). I would have thought it was safe to assume that drug prices are comparable across the board. After all, that’s how it usually works, right? When I buy gum, I have faith that I won’t pay triple the price at one convenience store compared to another. But with pharmacies, this just isn’t the case.

When we call a shopper “smart”, we assume that there are options to choose from and information to help choose between those options. That’s the market, and it keeps costs down for the consumer while encouraging the suppliers to find bigger and better ways to provide their product. If we don’t have options, or we don’t have information, we can’t have “smart” shoppers. A convenience store can charge me $6 dollars for gum, and if I have no way of knowing that gum usually costs $2, I’ll pay it. I can’t be running around with bad breath.

That’s why transparency is so important to the prescription medication consumer. Few of us have any idea as to how much drugs should cost. And, since many states don’t require their pharmacies to release their drug costs unless someone is buying them, the consumer has no convenient way of amassing the information it needs to choose from the options. Sure, I could make a trip to every nearby pharmacy and ask, but when is the last time you called ten different airlines to find the lowest price? When I buy airfare, I use one website that shows me the lowest fares for my trip from a range of different flight providers. Why should buying prescription drugs be any different? What’s more, a transparent pharmaceutical pricing system seems to make sense no matter what side of the political spectrum you call home. For conservatives: don’t you love a market that pits different companies against each other to increase performance and lower costs? For liberals: isn’t affordable medicine for the uninsured enticing? It works for everyone and it’s the right thing to do, so let’s get it done.

Forbes.com

NBC Nightly News with Brian Williams

ABC/Channel 7 News 

Reach MD Satellite Radio 

Chicago Tribune 

AMA News 

ChiTown Daily News

Prepared Patient Forum 

United Way

1. Generic Alternative- Always always always, ask your doc if there is a reasonable generic alternative. This is ALWAYS the best option for you in the long run. However, if there truly is no generic medication that comes close, then check into either (or both) of the next two options.

2. Drug Specific Copay Programs- These programs are run by the manufacturers of the drugs, aka Big Pharma (BP). Usually, these discounts are given to all patients, regardless of income. But make no mistake, it is a way for BP to circumvent your insurance company’s cost control mechanism for prescriptions. By picking up part or all of the cost of your copay, BP trying to make their product more attractive to you and to your physician. But when the manufacturer stops offering the copay discount programs you will be back to square one. However, if according to your doctor, you must be on one of these drugs, then by all means, take advantage of the savings while they last. In the case of Enbrel, their Enbrel Support Card Program picked up the tab for six months worth of copays. To find out more info on whether such a program exists for your medication, there are many websites out there, including the manufacturer’s site. However, I found the following two websites particularly useful:

Internetdrugscoupons.com- This website shows you all available drugs that have coupons, copay and otherwise, associated with them. It’s an ugly little site, and ignore the annoying ads for a prescription savings card. But it couldn’t be simpler to use. And all the coupons I clicked on were still valid- so it seems like the folks behind it keep it up to date. According to the mission statement on the website “[The founder] assembled this database of drug coupons to make it easy for people like my elderly parents to save money on their medications.”

RxAssist.org- This is a super slick website that allows you to look up your medicines, albeit individually, to see what deals are offered. When you see a deal you click on the medicine and you are directed to the manufacturer’s website. According to the About section of the website, RxAssist.org was established in 1999 with funding from The Robert Wood Johnson Foundation. Apparently they also must get a big old pile of money from Astra Zeneca– since its logo is smack dab in the middle of the home page.

3. Disease Specific Copay Programs- There are many organizations that offer patients with specific diseases, such as cancer and HIV/AIDS, assistance with their prescription copays. These programs often require financial ability-to-pay information from you to qualify for assistance. Disease Specific Copay Programs is a very comprehensive list of copay and other assistance programs compiled by a BP-funded site called Partnership for Prescription Assistance, aka PPArx.org.

You should know that some of the vaccines are actually a SERIES, meaning that you need more than one shot to be completely vaccinated. Other shots require a consultation fee (i.e. a visit with the provider) that costs extra, too. Here’s a look at what the vaccines cost at the two clinic chains and at a private primary care clinic on the north side of Chicago. The private clinic prices are a cash-pay discounted price (a 25% reduction of the usual fee) for the vaccines. It is important to note that while the private clinic prices might seem comparable, there are a couple of caveats: 1. These prices do NOT include administration costs that can run between $41- $25 per shot series. 2. You need to be an established patient of the clinic to get these shots, which is not the case for the Minute Clinics or Take Care Clinics.

Another resource for the Chicago area only:
City of Chicago Public Health Centers Fast Track Immunization Centers:
ALL VACCINES FREE for children ages 0-18 years of age.
FREE FLU SHOTS for adults.
Vaccines are given on a first-come, first-served basis and are not given every day at some locations- so be sure and check the website for hours of operation.

Minute Clinic Price List (CVS):

Flu (seasonal) $30
Hepatitis A (series of two shots) (adult): $117 per shot
Hepatitis B (series of three shots) (adult): $102 per shot
IPV (polio): $96
Meningitis: $147
MMR (measles, mumps, rubella): $116
PPSV (pneumonia): $77
TD (tetanus, diphtheria): $76
Tdap (tetanus, diphtheria, pertussis) $92
HPV: not available

Take Care Clinic Price List (Walgreens):

Tdap (tetanus, diptheria, pertussis): $65
MMR (measles, mumps, rubella): $96
Hepatitis A: not offered
Hepatitis B (series of three shots): $80 per shot
Twinrix (combination of Hepatitis A and Hepatitis B; series of three shots): $96 per shot
Shingles (over 60 years old): $220
Flu : $30
Pneumonia: $64
HPV (series of three shots): 1st: $215 (includes a $30 consultation fee), 2nd and 3rd shots: $185

Private Primary Care Clinic Discounted Price List:

Tdap: $48
Flu: $30
Hepatitis A (series of two shots): $94 per shot
Hepatitis B (series of three shots): $71 per shot
Twinrix (combination of Hepatitis A and B; series of three shots): $120 per shot
MMR: $68
HPV (series of three shots): $180 per shot

Good news! Thanks to a LesliesList.org reader we recently came across a doozy of a website called PrepaidLab.com that offers cheaper labs for patients. Here are some of the price differences between the discount price at my northside clinic (C), PrivateMD (PMD) (another online testing site) and PrepaidLab (PPL).

Lipid panel (cholesterol) 45 (C) 48 (PMD) 25 (PPL)

TSH (thyroid) 75 (C) 45 (PMD) 27 (PPL)

CBC w differential 27 (C) 45 (PMD) 16 (PPL)

There are a few caveats:

1. You must go to a LabCorp lab to have the blood drawn.

2. You must order the correct labs- or have your doctor order them for you online in the office. There are a lot of tests that sound the same once you start searching for the tests you need so order with caution.

3. You must pay with a credit card up front.

4. They tack on a $9.50 processing fee per order.

One nice feature is that the site gives you the option of providing your doctor’s fax so your test results can be sent directly to your doc.