Medicare Your Coverage Options

Why is your doctor prescribing costly drugs?

Written by Trudy Lieberman

Recently Peggy, an Indiana woman and reader of this column, sent me a lengthy email about her 94-year-old mother who is rapidly spending down her minimal savings to pay for prescription drugs.

Peggy didn’t hold out much hope that prices would come down before it was too late for her mom. But she succeeded in lowering her mom’s drug costs and what she learned along the way can be helpful to others strapped by high pharmaceutical bills.

Her mother is typical of many women in old age who have only a tiny financial cushion to absorb the continual price hikes imposed by the drug makers.  She was raised during the Depression, didn’t work much outside the home, lived in a condo her son bought, and then moved to an assisted living facility almost two years ago.

The facility’s $3,100 monthly fee plus drug copays bit into her savings, which totaled about $30,000 when she moved to assisted living.  Government benefits earned by Peggy’s father who served in the Korean War, a very small pension from a former employer, and Social Security benefits cover all but about $600 of the assisted living fee. The rest comes from her savings, which now are about half of what they were in 2017.

While most of her mother’s drug copays and other out-of-pocket pharmaceutical expenses have been manageable, Peggy explained it was the $313 copay for a three-month supply of a well-known, heavily advertised blood thinner a cardiologist had ordered that was the biggest culprit causing her mother’s savings to shrink.

That was the price her mom was paying when she hit Medicare’s infamous donut hole last year.

Peggy said every time her mom visited the physician, the doctor told her she was lucky to take the expensive blood thinner instead of the other “stuff”, which he called “rat poison” implying a cheaper drug was inferior, even dangerous.  Peggy said at every visit he told her that she was fortunate to be taking something better.

Then a family member discovered openpaymentsdata.cms.gov, a database maintained by the Medicare program that reveals the amounts of money pharmaceutical companies pay to doctors in speaking and consulting fees, in research fees and for food and drink expenses. Her mom’s cardiologist had received nearly $80,000.

Peggy had a bad feeling about the doctor and switched her mom to another physician who kept her on the high-priced drug for a couple months. Then she was diagnosed with anemia, taken off blood thinners and prescribed low-dose aspirin.

In the meantime, Peggy’s husband had a heart attack and developed a blood clot.  His doctor prescribed a low-cost blood thinner that’s been on the market for years.  She said he’s doing just fine on the “rat poison” disparaged by her mother’s first doctor. His cost: a $6 copay every 30 days.

For a long time, impartial medical experts have thought that the choice of drugs and devices may be related to payments doctors receive from drug and device companies.

Since 2014 the Physician Payments Sunshine Act requires drug and device makers to report to the government the payments they make to doctors. The Medicare database is a treasure trove of some 11 million payments to physicians.

The online publication ProPublica found that drug and device makers gave more than $1 billion to doctors and hospitals from August 2013 to the end of 2016.  Some of them have received payments totaling millions of dollars.

However, the drug and device database may be one of health care’s best-kept secrets.

A study published in the British Medical Journal (BMJ) found that only about 3 percent of respondents said they knew if their own doctor had received payments from the medical industry. Unlike Peggy’s family, they had no idea that Medicare’s Open Payments database existed.

Most Americans don’t readily switch doctors, sometimes – even in the face of overwhelming evidence that the doctors performed badly. The Lown Institute, a Boston medical think tank, reporting on the BMJ study, concluded, “maybe we should be more open to switching doctors based on their relationship with industry.”

Peggy had some advice of her own: “Do the research. Did the doctor receive money to push the drug? Ask questions?  How much does the drug cost? Is it really a better alternative?”

This piece was published on Tarbell.org  on 3/27/19 and originally published as part of Rural Health News Service series, “Thinking About Health”, on 3/26/19.

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