Trying to Do No Harm
To the Patient's Pocketbook

Wall Street Journal

Benjamin Brewer, M.D
November 28, 2006

My 65-year-old patient with chronic kidney failure and high cholesterol just found out his Pravachol cholesterol medication is no longer a preferred drug on his Medicare Part D plan. He brought along his plan's preferred drug list for me at his appointment.

The booklet was about 35 pages long; he couldn't figure out what his drug choices were. I looked over the information and didn't see any cholesterol drugs listed.

We turned to the Internet on my wireless laptop and found the company's Web site. "What region are you in?" I asked.

"Region?" he said.

"Let's look at your drug card," I suggested. Region 18 it turns out.

After about 10 minutes of booklet searching, Internet navigating and further discussion, I came across pravastatin, the generic version of Pravachol. It was covered in the same 40mg dose of the name-brand drug he's been on for years.

The pharmacy should have just substituted it out since I checked "may substitute" on my computer-generated prescription. We had wasted a good 10 minutes coming full circle back to what he started on.

Patients are more concerned about the costs of their care than they were even two or three years ago. From the increasing number of patients who have plans where they need to pay more out of their own pocket up front, to the seniors who are doing their best to make the most of their new drug plans, to the people who lack coverage altogether, costs are a constant concern among my patients.

I can't speak for other practices, but in mine, we are doing our best to help our patients keep their costs down. We don't get reimbursed for the efforts, but we see helping patients with costs as part of our role.

Formulary-seek-and-find is one of the games we play about five times a day. When patients change plans at the start of the new year, requests to save them some money on their pharmacy costs will double. This process is easier with some companies and plans than others. Sometimes technology helps cut costs and sometimes it doesn't. I prescribe generic drugs mainly so I can avoid a lot of this hassle.

Another thing I do is try to be accessible to my patients. There are two goals here. One is to help them stay out of the emergency room, where costs are much higher than for office visits. Another is to try to treat problems before they develop into more-serious, more-expensive problems.

My patient George is a 69-year-old man with three chronic diseases -- diabetes, high cholesterol and high blood pressure. He gets by on $14,000 a year and relies on Medicare without a supplement for his medical coverage. He has Medicare Part D for his prescription-drug needs.

He called me at home once on the weekend for trouble with his diabetes. He was having symptoms of sweating, lightheadedness and confusion from low blood sugars. It was a combination of his diabetes medications and changes in his diet. I told him to eat immediately, cut down on his medication at the next dose and have a friend stay with him that day until he felt better and his sugar came back up. That call saved him a $1000 ambulance ride and $500 to $1000 at the E.R. Typically under circumstances like that, Medicare would have paid 80% of the allowable charges and he would have been responsible for 20%.

I saw him in the office recently for an infection the same day he became ill. It was an average Wednesday but we were busy. Still, we flexed the schedule for an urgent need. A lot of offices have a hard time doing that because they're chronically overbooked and patients have poor access. When a patient with a serious issue calls in and the schedule is already booked, they're referred to the E.R.

Access to primary care saved him from getting worse, being hospitalized and racking up bills he couldn't pay. I checked to make sure he was still taking his medications and quizzed him about his health and any new symptoms. I refilled his five medications and discussed some lab work he needed for follow-up of his problems.

On a recent Saturday morning I met a father and his infant son with an ear infection at the office so they could avoid an emergency-room visit.

Meanwhile, sometimes when I talk with patients about tests, I bring up costs, and they decide not to have the tests. Some of my pregnant patients opt out of screening ultrasounds ($350) and optional blood tests for Down syndrome ($340), which could lead to further, more-expensive tests, like amniocentesis. Passing on those tests is not the right decision for everyone. But some of my patients -- certain farmers in particular come to mind -- fully intend to go ahead with a pregnancy and are watching every dollar. For them, it could be the right decision.

Some patients want to skimp on needed health maintenance to save money. I have to sell some patients on the benefits of following up for blood pressure and diabetes, including the required -- and costly -- lab work. Some price-sensitive patients figure that since they feel good then they don't need anything. More often than not they have uncontrolled weight issues, blood-pressure problems or high cholesterol that we really should be dealing with.

I think my patients have better outcomes at lower costs because they can actually get in to see me – or get a call or email returned the same day -- and because my chronic-disease care is better than average.

Would I like to be compensated for these efforts? Of course. For now, those of us out here in Region 18 will just keep on pluggin'.

Readers are strongly urged to post questions and comments in the Doctor's Office Forum, in which Dr. Brewer participates. You may also write to Dr. Brewer at thedoctorsoffice@wsj.com. Dr. Brewer cannot always respond to all the reader mail he receives.