This morning, I picked up two prescriptions at the local pharmacy. For a month’s supply of prednisone, I paid 63 cents. For a dozen Becton-Dickinson 3 ml syringes, I paid 56 cents.
Thereon hangs a long tale about prescription drugs, what they cost, and what they do. It is also a tale about how the U.S. health care system works — and it works better than it is popularly supposed to work, if not yet quite as well as it could. Pay attention.
I have a kidney transplant. It has worked for 21 years, but, in the last several years, it has gradually started to fail. My basic drug regimen for most of those years consisted of Imuran, a brand-name immunosuppressant, and prednisone, a generic anti-inflammatory.
A month’s supply of Imuran costs $11.60.
Why these varying charges? My wife and I have chosen a so-called “80/20” health insurance plan, classic indemnity insurance. The insurance company pays 80 percent of medical charges; we pick up the remaining 20. The alternative, which most insured people choose, is a “co-pay” system under an HMO (health maintenance organization) or PPO (preferred provider organization). Under the HMO/PPO system, you pay a flat fee for every doctor visit or every prescription, typically five or ten dollars.
The co-pay system sounds like a good deal, but it may not be. My month’s supply of Imuran and prednisone costs me $12.16. Under a co-pay system, I would pay either $10 or $20, for the same thing. Add a third regular generic drug to my regimen, and I would save money, even with an Rx co-pay of only $5.
Co-pays disguise cost, both from the consumer (who ultimately pays, one way or the other) and from the doctor, who prescribes without taking cost into account. What does it matter, if most patients simply fork over the same flat fee for a drug?
It matters a lot. My third drug, added many years ago, turned out to be a modern patented form of Vitamin D, called Rocaltrol, made by Roche. Generically, it’s known as calcitriol. People with impaired kidney function have screwed up calcium-phosphorus balances, and tend to lose calcium from their bones, leading to stooping, humped shoulders, and broken bones. We can’t just take over the counter calcium; we can’t absorb it normally. But with calcitriol, we can.
Problem is, insurance companies regard calcitriol as a vitamin, and they don’t cover vitamins. Some insurers will relent if you have a doctor write a letter explaining the situation. Others — like our current one — won’t even accept an appeal on the matter.
I pay $2 per pill for calcitriol. Ironically, if my doctor were to prescribe the injectable form of the drug, Calcijex, which costs four or five times as much, the insurance company would pay for it. Go figure.
My fourth drug, added two years ago, is erithropoitin, an injectable that made the news as an illegal performance enhancer during the last Olympic games. I take a shot twice a week to keep my sagging red blood cell count up. Kidney patients use EPO; so do cancer patients undergoing chemotherapy. It keeps us walking around and living normally. Initially, with a dose of 3,000 milliliters two times a week, my 20 percent share of the monthly cost was $56. As my kidney got worse, and my dose went up to 10,000 milliliters twice a week, the cost escalated, too — dramatically.
But there’s a glitch in the system here, also a product of the disguised cost routines of a flat co-pay. Two companies make versions of EPO. Procrit costs almost twice as much as Epogen. I discovered this only by accident, when one of my doctors carelessly wrote a prescription for the cheaper medication (there is no functional difference between the two).
In a rational health care system, with the costs out front, the price differential between Procrit and Epogen would be traded away — in favor of the lower price.
Last Tuesday, Douglas Forrester won the New Jersey Republican primary. A Democratic consultant, yacking on TV that evening, revealed what the talk show’s host jokingly called “the Torricelli talking points” (Forrester will oppose incumbent Democratic Senator Robert Torricelli in the fall).
“Douglas Forrester is a pharmaceutical executive,” said the Dem flack. “He made his money on the backs of our parents and our grandparents. I can’t wait to tell people what he’s really all about.”
Got that? Pharmaceutical executives and companies are evil because they make expensive prescription drugs.
I, for one, want to thank America’s pharmaceutical companies for those expensive drugs. They have kept me alive for 21 years after I could have died, and would have, through most of our history. They have kept me functioning actively and out of the hospital and off dialysis. They have spared me broken bones and kept me breathing. And now, as I head toward another kidney transplant, expensive drugs will give me a renewed life once again — an absolutely normal life, making a living, taking care of my kids. Drugs will be more expensive this time around, and a good thing, too. Improved immunosuppressants have boosted the success rate for live related donor kidney transplants from about 65 percent, at the time of my first transplant, to better than 90 percent today.
The alternative is far more costly, both to individuals and to society. The bill is paid in hospital stays, ambulance fees, emergency room visits, and lost productivity. The bill is paid, not to put to fine a point on it, in death. And if drug companies make money on the process, well, that’s how it works: Without the profits, there would be no drugs.
Come fall, you may find me standing next to Douglas Forrester, explaining all that and shaking his hand. I might say something else, too, just to prove that I can be as mean as a Democratic consultant. I might say, “Robert Torricelli wants me dead.”