The High Cost of Medications

PROBLEM: According to a February 2004 poll conducted for the Associated Press, one of every three respondents said that paying for prescriptions was a problem for their families.¹ Of those, three out of every four said they had put off filling their prescriptions or cut back on doses because of the cost. One in 10 people also admitted to buying prescription medications illegally from Canada, Mexico, or another foreign country to get a better price.

Of course, these alternatives to the high cost of prescriptions are not necessarily safe. Taking partial doses of prescribed medications or delaying treatment because of cost constraints places patients at risk for harm. And while lawmakers debate bills that would make it legal to purchase prescription medications from foreign countries like Canada, the Food and Drug administration (FDA) claims that it is difficult to verify that foreign drugs are safe. Certainly, some Internet-based pharmacies in Canada and other foreign countries do provide safe medications to U.S. citizens. Yet the FDA has also intercepted thousands of counterfeit medications coming into the U.S. from foreign pharmacies, some even claiming to be from Canada. Furthermore, if problems arise during treatment, patients may be reluctant to tell their health care providers that they purchased a medication from a foreign country or that they were unable to take their medication as prescribed because of financial difficulties.

Case Studies

A woman with a serious bleeding problem waited several days before admitting that she had filled her prescriptions in Mexico. She had arrived at the emergency department with bleeding gums; conjunctival bleeding; and ongoing pain, swelling, and discoloration of her foot for several days after stubbing her toe.

The patient’s laboratory results looked dangerously similar to those reflecting an overdose of warfarin (Coumadin, Bristol-Myers Squibb). Her prothrombin time was 105, the International Normalized Ratio was 13.9, and the partial thromboplastin time was 91.8. However, she denied taking warfarin and claimed that she had not been exposed to rodenticides. After she was admitted to the hospital, her physician actually refused to let visitors bring in any food for her because he was worried that someone was trying to poison her!

Two days later, the patient finally told her physician that she had recently purchased a prescription for ramipril (Altace, King) 5 mg from Mexico. When her family brought the medication into the hospital, the staff noticed that the prescription label said “Altace 2 Day,” but the manufacturer’s label underneath the pharmacy label said “warfarina” 5 mg. The patient had been taking 5 mg of warfarin twice daily for three weeks.

Another patient found it difficult to tell her health care provider that her prescription benefits had run out. In November, her physician had prescribed an antihypertensive medication to control her newly diagnosed hypertension. Sadly, she was too embarrassed to tell the doctor that she could not afford to fill the prescription until January, when her insurance limits would be renewed.

When her blood pressure was still elevated in December, her physician increased the dose. Then in January, when her prescription benefits were reinstated, she filled the newer prescription for the higher dose. Her blood pressure dropped dangerously low, and she had to be hospitalized for treatment.

SAFE PRACTICE RECOMMENDATION: There are no easy solutions to the high cost of prescription drugs, but there are often safer alternatives than cutting back on doses or buying medications from a foreign country, where FDA oversight does not exist. Here are a few steps for health care providers to consider:

1. Assessing the patient’s financial capability. Many times health care providers might not know that a patient cannot afford to fill a prescription. Thus, patients’ ability to purchase prescription drugs should be assessed in a way that will not embarrass them. The prescriber could add prompts to assessment forms to ask patients whether they have recently cut back on doses or have delayed filling prescriptions as a result of financial constraints. The number of uninsured Americans has never been higher, but even patients who do have insurance may find it a financial burden to buy prescription and over-the-counter medications.

2. Consulting with a pharmacist. If patients indicate that they might encounter financial difficulties with obtaining prescribed medications upon discharge, they should be advised to consult with a pharmacist, who can then communicate with the attending physician to suggest less costly medications or who can ask the physician to provide samples to tide the patient over until other sources of financial assistance can be located. If samples are offered, the pharmacist should ensure that the patient has no potential allergies or cross-allergies and has not had any serious drug interactions between the sample medications and any other medications being taken. Pharmacists should also remind patients to ask their doctors for written directions that can be kept with the samples for reference.

3. Directing patients to assistance programs. Many government-sponsored, pharmaceutical company–sponsored, and private patient-assistance programs can help eligible patients obtain lifesaving drugs at no cost or at a significant discount. For example, health care providers can direct patients to the following Web sites, and they should make sure their social services and case-management departments are aware of the existence of these resources:

   • Helping Patients (www.helpingpatients.org)
   • BenefitsCheckUp (www.benefitscheckup.org)
   • Medicare (www.medicare.gov)
   • RxAssist (www.rxassist.org/default.cfm)
   • Needy Meds (www.needymeds.com)

4. Alerting patients to the risk of buying drugs from Internet sources. Some Internet-based pharmacies are not properly licensed, or the medications may originate from a foreign country where counterfeit drugs are rampant. Patients should be advised to make sure that the Internet pharmacy they intend to use is properly credentialed. Patients can look for the National Association of Boards of Pharmacy Verified Internet Pharmacy Practice Sites seal on the Web site to ensure proper licensing and safety. Other verification sources are also being sought in Canada to provide consumers with confidence that drugs purchased online are safe.

5. Investigating problems. If clinical problems arise, it should not be assumed that patients have been taking their medications as prescribed. Health care providers should always ask patients about their compliance with regimens in an empathetic, nonthreatening way before changing the plan of care or increasing the dose of previously prescribed medications.