Intentional medicine price inflation?
August 5, 2018 5:54 PM   Subscribe

I recently went to a Minute Clinic and was prescribed one antibiotic for treatment for a minor bacterial infection. As I was filling the prescription, the clerk mentioned that it would likely be around ~50 dollars. The pharmacist then realized that they didn't have that particular medication in stock, called back to the nurse and asked if they could substitute. The substitution medication was 5 dollars. What would explain the price difference, and are doctors pressured to push pricier but equivalent drugs on patients?

It was for conjunctivitis, and both meds are antibiotic eye drops.
posted by codacorolla to Health & Fitness (14 answers total) 4 users marked this as a favorite
The cost of the drugs generally has to do with how old it is. Newer drugs that don't have generic equivalents are more expensive. Older drugs are less expensive, and older drugs also usually have generics that are even cheaper than that.

Sure, doctors are human and some of them are susceptible to "encouragement" from drug company reps to get their patients to try new drugs. However, in my experience, doctors are pretty clueless about how much different drugs (and procedures) cost.
posted by radioamy at 5:58 PM on August 5, 2018 [2 favorites]

It could have been that the initial rx was for tobradex (antibiotic with steroid) but since they didn’t have it, they substituted with tobramycin (abx w/o steroid)?
posted by tatiana wishbone at 5:59 PM on August 5, 2018

tatiana: yes, I think so. The current drug is definitely tobramycin, and the other name sounds familiar.
posted by codacorolla at 6:07 PM on August 5, 2018

When you get a prescription, always ask the doctor to mark it so that you can substitute a generic if that's available. That way if you get to the pharmacy and there is a cheaper generic, you can receive that instead. If the Rx is marked a certain way, the pharmacy can only give you the name-brand, even if the generic is much cheaper.
posted by mccxxiii at 6:45 PM on August 5, 2018 [3 favorites]

I can't find it now, but there was an essay in the New York Times a few years ago by a doctor who didn't think he was influenced by the perks he was getting from drug companies, but when he examined his prescribing habits, he found he actually was prescribing more drugs from companies who had paid him. The drug companies aren't stupid. They're spending this money for a reason. I think that most doctors are either (a) cocky enough to think they're above being influenced when that's exactly what's happening or (b) just completely clueless about drug prices. And there are probably some who are prescribing drugs knowing they've been unduly influenced.

Propublica has a database
where you can check to see how much money your US doctor gets from drug companies.
posted by FencingGal at 6:47 PM on August 5, 2018 [9 favorites]

I think the first two answers address both parts, but to combine it - and this is my experience only:
Generally, as a prescriber, I don't usually think of price initially. First-line is 'okay, what medication is the right one?' Symptoms, age, allergies, side-effects.

Another thing I'll think about is 'will this be annoying for the user?' I think about this because annoying medications, like something you have to take 4 times a day, or two separate eye drops, are less likely to be taken correctly than a single drop or a once a day med. That said, a once-a-day med might be newer and/or more expensive than an older 4-times-a-day med.

Finally, I'll be aware of price in certain situations - like if I know someone doesn't have insurance - or for certain medications. I'll check the Walmart/big chain pharmacy $4/5 dollar lists at discharge for substitutes. If I see a lot of conjunctivitis I'd probably be eventually aware that Tobradex can be $$ versus the non-steriod Tobramycin. If no one complains, I might not realize it for months/years.

I've found we often get used to prescribing from a mental list - which may be influenced by drug reps, but often is more a combination of a factors like where you have been working, what prescribers you trained with or work with tend to write for, your personal experience with certain drugs and their results. A good example are steroid creams - there's a billion, sorted into strength levels, and usually a provider settles on one from each strength level as their 'go to'. This can be modulated by things like preferred drug lists by hospitals/insurance companies as well as experience with the use. This is where I might be aware of cost early ('AwfulCo won't pay for Levobecalp, we have to use plain old Obecalp.')
posted by cobaltnine at 6:51 PM on August 5, 2018 [20 favorites]

which may be influenced by drug reps,

Honestly, it's not "may" - the connection is well-established, indisputable, really:
Doctors tend to prescribe drugs that pharmaceutical companies promote to them and patients end up paying more but not always getting the most suitable medicines, researchers reported on Wednesday.

An analysis of 58 studies in several countries found that information from drug companies influenced the decisions doctors made, and not necessarily in a positive way.
I agree, in that it's certainly not the only factor - like you, I think GPs tend to get a list of "favourites", and will stick to them barring some a compelling reason not to. However, I think pharmaceutical bribery plays a larger role in the generation of that list than most GPs are willing or able to admit.
posted by smoke at 8:26 PM on August 5, 2018 [4 favorites]

What would explain the price difference, and are doctors pressured to push pricier but equivalent drugs on patients?

Even without any external push, I think it can be very hard for providers to keep track of pricing because it can vary greatly depending on if /what insurance plan an individual patient has. Not to mention it can change. Several years ago my PA prescribed a Vitamin D supplement. I got to the pharmacy and they told me my insurance wouldn't cover it "any more*." I called my PA who was very surprised and apologetic (not that she needed to be! I wasn't upset) and told me to just get the OTC. The script version I would have just had to take 1 x week (instead of daily, so possibly she has better compliance with it), and she was so used to it being covered she thought it was going to be cheaper for me.

*I'd never had to take it before, so I'm no sure if it was a recent change.
posted by ghost phoneme at 8:42 PM on August 5, 2018 [1 favorite]

Just ask if there's a generic when you go to the pharmacy. Mine actually fills with generics by default unless you specify otherwise or there is no generic.
posted by DarlingBri at 1:40 AM on August 6, 2018

Doctors do not seem to consider or even be aware of the price of their services and prescriptions—they tend to just do whatever they think is the best option medically, and damn the cost. I wish they were better at that stuff, but hey medical pricing in America is chaos, and they have staff who deal with that stuff. Can't be an expert at everything. Still, I wish they were better at it—the most effective medication is only most effective if the patient can afford to use it.

And yes, physicians are totally pressured/incented/persuaded/encouraged to prescribe expensive new medications. Some of them even receive kickbacks, in one form or another. It's not a good thing, but they're humans and so they're as vulnerable to sales and marketing tactics as anybody else. There's been increasing awareness of just how much doctors are influenced by pharmaceutical salespeople, but I don't know if it's translated into any meaningful change in the status quo.
posted by Anticipation Of A New Lover's Arrival, The at 2:18 AM on August 6, 2018 [1 favorite]

My prescribing mentality is similar to cobaltnine's. Frankly, every electronic medical record I've seen contains no information about pricing of anything. I went in and set my e-prescribing to default to generic, but even finding that option was opaque. There is also minimal to no education about price and/or value -- in 10 years of medical school and training, I had exactly 2 hours of instruction on health economics: one small group session where we had to role-play the insurance company denying claims, one grand rounds lecture where the speaker analyzed the value-for-money of lab testing for young-onset stroke. It's not intentional price inflation, but it's a massive blind spot in medical education.

As to drug companies, straight up kickbacks are illegal, but people are absolutely influenced by drug company dinners and honoraria to go speak at a "conference" in Hawaii. If you're concerned about that, you can check the Sunshine Act Open Payments site.
posted by basalganglia at 4:08 AM on August 6, 2018 [4 favorites]

Similar to several responses above-- Not only do I work in an academic medicine environment that is "pharm-free" (as in, literally no pharma reps allowed on campus, no one is allowed to accept so much as a pen or a cup of coffee either on campus or off), but I have essentially no idea which medications are more/less expensive. There are "recent" drugs (things that have come into the market since I finished training) that I would assume remain more pricey-- but in terms of the medication I would choose it's 100% due to my perception of efficacy, side effect profile, likely compliance, etc. Occasionally I will have a pharmacist call me when a patient fills a prescription, wondering if there is a cheaper alternative, and I'm always happy to choose from a list of medications I think will address the diagnosis...
I honestly wish I knew MORE about prices; it's not my intention to add anxiety/money worries to patients' lives...
posted by BundleOfHers at 9:37 AM on August 6, 2018 [2 favorites]

I also wanted to add that the pricing can vary wildly by insurer and even within plans for an insurer. I have several long-standing topical prescriptions for very common drugs that have been available as generics for years. They've always been on the lowest generic tier for any insurance plan I've been on ($5-$15 depending on the plan). My company switched plans last year within the same insurer, and those meds all went from $10 to $60 without warning. I even checked with our benefits rep and she confirmed this was correct. I'm sure my doctor has no knowledge of this.
posted by radioamy at 11:11 AM on August 6, 2018

I also work in an academic environment and haven't even met a drug rep in over 10 years, but the local hospital and insurance formularies tend to have a big effect because that's what you end up being familiar with.

I have a pretty good idea of what's a cheap generic and what's a new and $$$ drug, but different insurance companies tend to have a lot of variability in terms of which of several reasonable options would be covered.

I prescribed a patient Ciprodex drops (ciprofloxacin with a steroid) for an ear infection a couple of weeks ago, then got a call from her saying it wasn't covered and was going to be $80, so I changed it to generic ciprofloxacin drops, only to get another call from her with the same message. At that point it required 20 minutes on the phone to get the pharmacist and find out that her insurance preferentially covers ofloxacin drops (a different antibiotic in the same class, also generic) and that ofloxacin would be $10. Other patients have had the opposite experience. It is literally impossible for me to keep track of which medications are covered by which plans, for the vast majority of drugs, so I generally don't bother to do it--I'll prescribe the one that 1) I think is most medically appropriate, 2) easiest to take, and 3) what I think will be least expensive. I have a pretty good chance of getting 1) and 2) and a substantially lower chance of being right with 3).
posted by The Elusive Architeuthis at 9:02 PM on August 6, 2018 [1 favorite]

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