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May 2017

The Cost of Medicine: Anticipating Drug Costs at Discharge

Allison NuovoAllison Nuovo, MD
PGY2, University of Utah

After making a happy transition from the life of a medicine intern to a PGY-2 PM&R resident, there is one thing I miss dearly; rounding with a pharmacist. On the inpatient rehab unit at our hospital, there is 1 pharmacist for an entire floor of about 40 patients; they do not round with us. This places more responsibility on the resident to anticipate medication costs for patients as they prepare for discharge, which is a great learning opportunity. I realize I have many years of education covering what to prescribe, side effects, etc. That said, I have no clue what medications actually cost. Until recently, I had no idea how to go about learning this.

Many of my patients use lidocaine patches to alleviate localized pain. They work. I personally feel that my patients’ narcotic use decreases with these patches. I order them on discharge, then get a call from the pharmacy shortly after, telling me that those patches are expensive, they won’t be covered, and the patient will either have to do without them or pay $200 for a 1 month supply. I thought lidocaine was cheap. As it turns out, these patches are indicated only for post-herpetic neuralgia or diabetic neuropathy.

It goes this way for many drugs we commonly prescribe. There are rushed, last-minute conversations with patients to change medications on the day of discharge due to challenges with coverage. As a provider, I feel this is a big issue. Date of discharge changes could lead to poor medication compliance, confusion from patients about what they should be taking or poor pain control that might limit the ability to adhere to a therapy program as an outpatient. What if, because the lidocaine patch is not available, the patient decides to increase their oxycodone dose? We should not reach for systemic pain pills, narcotics, to treat something that is well managed by a topical medication.

I realize there are many definitions of cost. There is the cost to the hospital, for instance, what the hospital pays for Lyrica is much less than the commercial street cost of Lyrica. Different insurance companies cover different medications. Uninsured patients often have their hospital discharge medications covered by charity, and don’t pay anything regardless, at least for the initial fill.

The big dream is transparency between insurance companies and prescribers. This has been a goal from larger organizations than us for a long time. It would be great to pull up a drug in our EMR and see whether or not it will be covered by insurance. In the meantime, we are focusing on ways to improve the communication between our discharge pharmacy and the residents writing orders, and educating our residents about expensive medications commonly-prescribed and alternatives, which may be better covered.