Interesting Article of the Week Plus Price Check!

An acquaintance complained to me recently that he was struggling to afford his medications, which cost him a couple of hundred dollars a month.  I looked at his medication list and saw (among other examples) that he had been prescribed the statin Crestor, which costs $5.00 a pill, even though generic simvastatin costs just 3 cents a pill!  He was prescribed the Angiotensin Receptor Blocker (ARB) Benicar ($4.26 a pill) even though the generic ARB losartan costs 7 cents a pill.

When I called the prescribing doctor on behalf of this patient, the doctor readily changed his prescriptions to the more affordable brands.  But why would he prescribe expensive stuff his patient couldn’t afford in the first place?  That is the subject of our interesting article of the week.

Ann Pharmacother. 2012 Feb;46(2):200-7. Epub 2012 Feb 7.

Assessment of prescribers’ knowledge of the cost of medications.

Cogdill BNappi JM.

(Click here to go to the PubMed citation)

This study assessed physician and medical students’ knowledge of drug prices. The prescribers in the study did amazingly poorly on a test of their knowledge of drug prices.  That didn’t surprise me.  What did surprise me, however, that the prescribers seemed not to care that they did not know drug prices! They didn’t seem to think it was important.  These prescribers also routinely prescribed medications without knowing or checking whether their patients had insurance that would cover the drug.

This attitude may be common (common?  Almost universal!) in the outside world of medicine, but it has no place in Correctional Medicine.  We prescribers who work in correctional facilities need to have an idea of what drugs cost.

  1. Most of our patients will eventually get out of our jails and prisons.  Most of them will not have medical insurance.  We need to prescribe medications that they will be able to afford.
  2. Besides being medical practitioners, we also are stewards of the money the county or state spends on medical care within our facility.  Every dollar that we spend needlessly is a dollar that cannot be used for something else.
  3. Besides looking for effective medications, we also need to look for medications with high value.  Value is a concept that seems to have been forgotten in modern medicine, as practiced in the United States at least.

What is the Value of a Drug?

The “Value” of a drug can be defined as the benefit of that drug divided by its cost.  If medication A and medication B both achieve the same result, but medication A is 20 times more expensive than medication B, then medication B has 20 times more value.

Sometimes, new and expensive drugs are touted by drug reps as having, say, “17% improved relative benefit” over the old, generic drug.  Almost always, these claims are unfounded or the difference is clinically meaningless.  But even if it is true, the generic drug  will still usually have more Value.  Nexium versus omeprazole is a good example.  AstraZenica, the maker of Nexium, claims that Nexium provides slightly better stomach acid control than does omeprazole.  Most experts do not believe this, but even if it is true, omeprazole costs 10 cents a pill, whereas Nexium costs $6.15 a pill.  Is Nexium 61 times more effective than omeprazole?  The answer is, of course, no.  Instead, omeprazole is 60 times more Valuable than is Nexium.

So why is Nexium one of the best selling drugs in the world?  The Interesting Article of the Week has the answer:  Because U.S. doctors don’t know how much Nexium costs and they don’t care.  Sad.

Let’s make sure that we Correctional Medical Specialists know the basic price of the drugs we use.  To do this, we need a source.  Your pharmacy is one source.  Have your pharmacy do a price comparison for you on a different category of drug every month.  You can also find the acquisition cost of most medications online.  Here is the one I use:  The Idaho Average Acquisition Cost Drug List.  It is published by Idaho Medicaid and is updated every two weeks.  You can find it here.

Price Comparisons

Here is the Average Acquisition Cost Drug List price for the medication classes I discussed in today’s post:

Angiotensin Receptor Blockers

Generic Drugs Brand Name Drugs Price per Pill
Losartan (Cozaar)50mg $0.07
Irbesartan (Avapro)150mg $1.83
Atacand (candesartan) 4mg $2.79
Benicar (olmesartan) 40mg $4.26
Diovan (valsartan) 40mg $2.67
Micardis (telmisartan) 40mg $4.02

Comment:  If you have to use an ARB rather than an ACE inhibitor, why would you use anything other than losartan (at least until the price of irbesartan falls to comparable levels?)

Statins

Generic Drugs Brand Name Drugs Price per Pill
Atorvastatin (Lipitor) 20mg $0.22
Simvastatin (Zocor) 20mg $0.03
Pravastatin (Pravachol) 20mg $0.07
Crestor (rosuvastatin)20mg $4.99
Livalo (pitavastatin) $4.14

Comment:  Note that atorvastatin is rapidly falling in price and will soon be comparable to simvastatin and pravastatin.  Lipitor was once the top selling drug in the world!

Proton Pump Inhibitors

Generic Drugs Brand Name Drugs Price per Pill
Omeprazole (Prilosec) 20mg $0.10
Lansoprazole (Prevacid) 15mg $1.27
Pantoprazole (Protonix) 20mg $0.09
Nexium (esomeprazole) 20mg $6.15
Dexilant (dexlansoprazole) 30mg $4.67
Aciphex (rabeprazole) 20mg $8.61

Comment:  Note that pantoprazole (Protonix) is now even a little less expensive than is omeprazole!  And remember that omeprazole also has an OTC formulation, so you can put it on your commissary, so inmates won’t have to come to you to get it.

Do you track drug prices at your facility?  How do you do it?  Please Comment!

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2 thoughts on “Interesting Article of the Week Plus Price Check!

  1. Mike Summers

    At our facility( County jail), there is a meeting with the prescribers each month and a main topic of discussion is drug utilization and the cost of the most commonly prescribed medications. Our Pharmacist tracks the cost of medications and provides a break down of the cost of each drug with high utilization. We currently have some auto substitutions in place; one of those is Omeprazole for any proton pump inhibitor. A significant cost in our facility is psychotropic medications; our psychiatrists are relatively young and have essentially “grown up” with the newer antipsychotics and have little experience with the older drugs; they have a tendency to order higher cost meds even to this population who won’t be able to afford them when released from custody.

    Reply
    1. Jeffrey Keller Post author

      Thanks for the comments, Mike! Your jail is way ahead of most correctional institutions if you not only track medication prices, communicate the prices to the prescribers and have automatic substitution policies in place. Well done!

      I understand the frustration of psychotropic drug prices and the devotion of some to the expensive meds despite the evidence. Maybe that will change now that more of the atypical antipsychotics, like risperidone and olanzapine are now generic and are getting cheap.

      Reply

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