Nevertheless, most of the women who are taking replacement estrogen are younger women who have had a total hysterectomy. Since these women are young, it is appropriate for them to take replacement estrogen. Since they do not have a uterus (for the most part), they do not need to take progestin. But which estrogen should be on our “Preferred Drug List” (otherwise known as a Formulary)?
In many drug categories, ACE inhibitors, say, there are several options that are equally effective and equally priced. I don’t care if a patient is taking lisinopril or enalopril. They are equivalent.
That is not the case with estrogens. It turns out that in the estrogen department, there is a clear winner.
Here is the price-per-pill breakdown. The doses listed are the typical standard doses for adult women.
Premarin has been around since 1942 and for many years, was the only available estrogen product, to the point that “Premarin” became almost synonymous for all estrogens in the same way that people say “Kleenex” for all nose-blowing tissues. Premarin continues to be the most prescribed replacement estrogen.
In fact, however, all of the estrogens are therapeutically equivalent. The only differences are these:
1. Premarin (conjugated equine estrogen or CEE) is derived from pregnant horse urine. That is the only thing (except price) that sets it apart from the others.
2. All the others, including synthetic conjugated estrogen, are made from plant proteins.
3. 17-beta-estradiol (usually just called estradiol, brand name Estrace) is the only formulation that is “bio-identical” to human estrogen.
So there you have it. By curious happenstance, the one estrogen that is bio-equivalent to human estrogen happens to be the one that costs 4 cents a tablet.
Estradiol should be the preferred estrogen in your facility.
Do you still use Premarin in your facility? Why or why not? Please comment!
My good friend Al Cichon wrote the following comments to me about my article on the 10 Point Pain Scale.
Use of a ‘scale’ to measure subjective factors is a true oxymoron (heavy on the moron part). The ‘fifth vital sign’ is a misdirected effort to solve a true quality care problem – in my opinion. Vital Signs are objective (as in measurable) indicators that have been demonstrated to provide consistently valid data for patient care.
JCAHO has imposed the ‘Pain Scale’ in an effort to assure that the assessment of pain will be factored into patient care. Unfortunately, it is a bureaucratic response to a clinical situation – if it can be made to be measurable (regardless of practical validity) it can be enforced. My apologies to proponents and defenders – but no matter how well intended; it is still dysfunctional.
Yet, we are obliged to employ some process of assessment to determine the impact of subjective symptoms in an efficient / effective manner. The many schemes (Pain 1-10; Cardiac pain 1-5; etc.) developed have achieved relative success / adoption / adaptation. It does seem that these processes have provided some benefit – yet they all suffer from the same susceptibility – subjectivity. Whether you are working in corrections (where any subjective report must be verified) or the community (where verification is not always considered) any of these schemes has the same risk – because there is no objective validation.
One possible option to stabilize the use of any such scale is some method of anchoring the initial or end point of the scale. That would then provide a somewhat stable reference for guiding care and transmitting information (about the patient) to other providers. Also, this mechanism can be employed in other subjective areas.
Begin with asking the patient – ‘What is the worst pain you have ever experienced?’ (the response is usually associated with fractures, renal calculi, child-birth, etc.) Now, lets’ label that as a 10 (or 5) and now –‘What is the discomfort you have now in comparison to that prior event?’ Then document the exchange in the record: Worst Pain: fractured wrist – 10); Current Pain: pulled muscle – 7. Now, no matter the number system you have an ‘anchor’ to both the scale and the present condition that can be related to the care process and others. It is important to document the ‘source’ of pain too – as this may be quite useful if you are explaining the case later (DOC, court, etc.)
One variant of this is: If you had a ‘bucket labeled depression and a stick marked off from 0 to 10 what is the worst you’ve ever felt and when”? The response will then provide an anchor (9 when I was admitted to the hospital after trying to kill myself). Additional questions are: How deep is that bucket now? Has it ever been at 0? If I could make it happen (wave magic wand) and get you released and home now – what would it be? (interestingly it can go up with release for many reasons)
When you ‘anchor’ the ‘pain scale’ it establishes the assessment in a relatable setting and can be quite helpful in guiding patient care. The ‘anchor’ can also be quite useful in discerning the ‘historical validity’ of the case as well – ‘Doc when I had that car accident with multiple fractures it was a 10; now my sprained (non-swollen, non-bruised) ankle is a 10 too!’
Clinical judgment is always the most important skill in any patient care situation. The data subjective & objective is helpful but must be understood / applied in the clinical context.
Also confounding the assessment is the different types of acute / chronic discomfort (myofascial, neuropathic, visceral). As important as assessing the level of pain is the type – physiologic source – since it is critical in guiding treatment.
As noted – ‘chronic pain’ is better measures by an assessment of the patients ADL (what daily activities are disrupted and is that new). If a patient can function (nutrition, hygiene, elimination) and participate in some activities then treatment of the physiologic cause is the most important clinical consideration.
Just because you assign a number to a complaint, that does not make it objective. Because each of these scoring systems assigns a number to the complaint, there is a tendency to think of them as objective rather than subjective. But as Al points out, this is not the case. There is no real difference between someone who says his pain is “a six” and someone who says that he has “moderate pain.”
In order for a subjective scoring system to work, it needs to be “anchored” in some way. Al anchors the 10-Point Pain scale on the patient’s own worst experience. Another commonly used clinical pain scale, the Visual Analogue Pain Scale, anchors the scale onto facial expressions. The more “anchored” a system is, the better it is. The less anchored it is, the less useful it will be.
The more numbers in the scoring system, the less reliable it becomes. Let’s say instead of a 10-Point Pain Score, we used a 1000-point pain score and were asking patients “would you say your pain is a 671 or a 672?” Of course, a pain score of “672” gives us no more useful information than a “6.” In fact, it gives us less useful information because it is more confusing. In a scientific sense, the more numbers a subjective rating system has, the less “inter-rater reliability” that system has. The simplest subjective scale has only two scores, “None (zero)” and “Some (one),” as in “Do you have pain or not?” The subjective scale perhaps used most often in daily life (Like when you go to a Thai restaurant and are asked how hot you want your food to be) is a four score scale: None, Mild, Medium, Severe. The Visual Analogue score is a 6 point scale. CIWA-Ar uses 8 points. And the 10-Point JCAHO Pain Scale uses 11 points (zero plus one through ten). Is the 10-Point JCAHO scale more accurate than a simple “mild-moderate-severe” system? Probably not. In fact, no “probably” about it. No.
Subjective scoring systems work better at evaluating changes over time than the initial severity of a symptom. If a patient says his pain is a “6,” I may not know exactly how that is different from a “7” or even a “4.” But later, when the same patient now rates his pain as a “5,” I am pretty confident that his pain has decreased, at least by a little.
Subjective scoring systems only work if the patient understands and is cooperative with the process. Al helps the patient to understand the process with his excellent “anchoring” technique (which I will be adopting, by the way). But the system still will not work if the patient always, no matter what, says “my pain is a 10.” That is the main problem I run into in my jails; deciding when patients are exaggerating their symptoms. For example, if a patient complains of “severe” constipation, what weight do I give to their use of the word “severe?”
There are two types of subjectivity in scoring, the patient’s and ours. The patient is subjective when rating her own pain or depression or whatever. Then we clinicians make our own subjective assessments. How sick does the patient look? Often, the two assessments do not coincide, as when the patient rates his abdominal pain as a ten while munching on Cheetos and looking bored. If I do not trust the patient’s own subjective assessment, sometimes I must substitute my own clinical judgment.
Scoring systems for pain perform worse for chronic pain than for acute pain. For chronic pain, a more useful assessment tool is to evaluate how the chronic pain affects Activities of Daily Living (ADLs). Is the pain too debilitating to hold a job? Play golf? Go to the store? Walk? ADLs are usually much easier to assess in a correctional facility than in the outside world. You can go down to housing and watch the patient. How easily does the patient sit, stand, walk? Does the patient go to recreation? Sit for long periods of time playing cards or watching TV? This sort of assessment is very useful for gauging the impact of chronic pain.
There are several good reasons to know what your pharmacy is charging you for each of the drugs you order. You need to know actual prices in order to assess the value of similar drugs, like two different first generation cephalosporins. In fact, you will have to know this in order to be able to set up a Pre-Approved Drug List. You need to know when a particular drug has a sudden price decrease or increase so you can switch to the most cost effective drug. Finally, you want to know that you are being charged fairly. If a pharmacy sells you a drug for 5% more than the price they paid to the wholesaler to obtain it; that seems fair. But if they jack up the price literally by 46 times, well, that does not go down so well. (See story below)!
Unfortunately, pharmaceutical prices are among the most convoluted and hard to understand of all drug prices. They are kind of like airline ticket prices. Have you ever heard of the game in which passengers on a commercial airline flight compare what each of them paid for their ticket with the lowest price being crowned the winner? (Their reward is the deep satisfaction that comes from knowing that everyone else is jealous of them). Airline tickets are kind of a unique item in the economy in that the price varies depending on many factors like when you book, how you book, how often you fly, how many bags you check and on and on.
Who Can Understand Pharmacy Industry Jargon?
Pharmacy prices are similar to this. What you pay per pill for drug X at your facility may be far different than what the facility down the street pays. The system is so convoluted, in fact, that it sometimes can be hard to even find out what your pharmacy is charging you and how they derive this price.
Pharmacies have their own professional jargon that can be hard for outsiders to understand—just like us! We say, for example, that a patient has an “erythematous urticaria” when we mean “itchy red rash.” Pharmacists say “I’m charging you the Average Wholesale Price minus 12%.” What the heck does that mean?
It turns out that there are many pricing systems in the pharmaceutical industry. You only really have to know about two of them, but it is worthwhile to peruse a list of the others:
Average Wholesale Price (AWP)
Actual Average Acquisition Cost (AAC)
Wholesale Acquisition Cost (WAC)
Average Manufacturer’s Price (AMP)
Maximum Allowable Cost (MAC)
Federal Supply Schedule (FSS)
Federal Upper Limit (FUL)
Estimated Acquisition Cost (EAC)
Average Sale Price (ASP)
Usual and Customary Charge (UCC)
And that is not all of them! The problem is that each of these pricing systems can give amazingly different prices for the exact same medication.
Fortunately, you only have to know about two of these pricing schemes; one that you don’t want to use and one that you do want to use. Forget about all of the others.
Average Wholesale Price (AWP)
The one that you don’t want to use is the Average Wholesale Price (AWP). Historically, this is the most common price system used by pharmacies. The problem is that it is a misleading term. You would think that the “Average Wholesale Price” would be the average price that the wholesalers charge for a drug. Well, you would be wrong. AWP is not a wholesale price and it is not an average. It is just a price set by the pharmaceutical industry. It is debatable exactly where that price comes from. However, AWP is, on average, 20% higher than the true wholesale price. But can be as much as 120% higher! That means if a pharmacy says to you “I’m going to charge you AWP less 12%,” that means that they will be making somewhere between 8% and120% profit on these sales. (They were probably smiling when they said it). And that is in addition to their “Fill fee,” which I will discuss in a future post.
In addition to being an inaccurate representation of wholesale costs, AWP is quite hard for the typical consumer, like you and me, to find. You can’t just look up AWP online. AWP are listed in certain pharmacy trade publications like The Red Book, but access to the Red Book is quite expensive. And even if you get one, you will find that a certain medication, say ranitidine 150mg, has not just one AWP like you would expect, but a bewildering array of AWPs that range in price from one cent a tablet to well over one dollar a tablet. Some AWPs apply only to hospitals, some to huge bulk purchases like Wal-mart would make. It is often almost impossible to decipher what would apply to your situation. I know. I have tried.
Some pharmacies really like to use AWP and I can see why. It has many advantages for them. AWP overestimates wholesale costs to the advantage of the pharmacy. The pharmacy understands it, but you don’t. In essence, AWP is what the pharmacy says it is! How are you going to know differently? If possible, do not deal with the AWP!
Average Actual Acquisition Cost (AAC)
The price that you want to use instead is the Average Actual Acquisition Cost (AAC). AAC is an estimate of the actual wholesale cost your pharmacy pays for medications. Instead of being head-scratchingly hard to understand, AAC is easy to understand. It is the true wholesale price. And instead of being almost impossible to find out, you can find out the AAC in one of two easy ways. First, you can ask your pharmacy for the AAC of medications you commonly order. Some pharmacies will give this information to you, no problem. If you have a pharmacy like this, consider yourself blessed. Other pharmacies can be quite loathe parting with this information.
Fortunately, there is a second way to find AAC prices: You can look them up online. Most state’s Medicaid programs utilize AAC to set Medicaid drug prices and publish the AAC on their website. If your state does not offer online access to AAC, feel free to use Idaho Medicaid’s AAC website, found here.
How Much Difference Does It Really Make?
Is the difference between AAC and AWP really that important? Here is a true story that illustrates the difference.
Like many doctors, I have a little black bag with some doctor tools and medications that I can use in urgent situations. One such “stat” medication that I keep in my black bag is ondansetron (Zofran), which is, of course, used to treat nausea. A couple of weeks ago, I went to a local chain pharmacy to get some new ondansetron for my black bag. I had looked up the AAC online before I went to the pharmacy and found that the AAC of generic ondansetron 8mg tabs was 15 cents apiece. For 30 of them, the total AAC would be approximately $4.50. Figure in a percentage markup and a fill fee and I thought I would be charged approximately $10.00-$15.00 for this prescription.
Instead, the pharm tech looked me in the eye and said “That’ll be $235.43.” The pharmacy had calculated the price using AWP!
$10.00 vs. $235.43. Now that is the difference between AWP and AAC in a nutshell. What would your facility have done had it been charged $235.43 for this prescription? Paid it without question, I suspect.
So getting back to the original question: Is it possible to understand pharmacy prices? The answer is Yes! As long as you use the Actual Average Acquisition Price. You can understand the numerous other pharmacy pricing schemes only if you understand their relationship to AAC.
Do you have a good relationship with your pharmacy? What do you pay for your pharmaceuticals? Please Comment!
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.
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.
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.
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.
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.
Here is the Average Acquisition Cost Drug List price for the medication classes I discussed in today’s post:
Angiotensin Receptor Blockers
Brand Name Drugs
Price per Pill
Atacand (candesartan) 4mg
Benicar (olmesartan) 40mg
Diovan (valsartan) 40mg
Micardis (telmisartan) 40mg
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?)
Brand Name Drugs
Price per Pill
Atorvastatin (Lipitor) 20mg
Simvastatin (Zocor) 20mg
Pravastatin (Pravachol) 20mg
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
Brand Name Drugs
Price per Pill
Omeprazole (Prilosec) 20mg
Lansoprazole (Prevacid) 15mg
Pantoprazole (Protonix) 20mg
Nexium (esomeprazole) 20mg
Dexilant (dexlansoprazole) 30mg
Aciphex (rabeprazole) 20mg
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!
It is a good idea to check on the current price of medications once in a while. When I do this, I am invariably surprised by price changes since the last time I looked. On the one hand, once a medication goes generic, the price will fall to a small fraction of what it used to cost. This process can occur quickly, say over 6 months, or may take a couple of years until it hits bottom. On the other hand, sometimes drugs that had been cheap, quickly and inexplicably become expensive. The current prices for antipschotics show both trends. Continue reading →
One thing that has long bugged me about how medicine is practiced in the United States is that medical professionals for the most part have no idea how much stuff costs. Doctors prescribe medications that their patients cannot afford to buy—even when cheaper alternatives are available. We order tests not knowing what the patient is going to be charged.
This phenomenon occurs nowhere else in American culture. It is kind of odd when you think about it. It would be like going to the grocery store and having no prices on any of the food. You could only get the meat that the butcher recommended, but he wouldn’t know the price of anything, either. The first inkling you would have about costs would be when you got your bill in the mail a month later: “Wow—that chuck roast was $200.00 a pound!” Continue reading →