Even before the current economic downturn, a third of Americans were without health care coverage, at least for part of the year. Now, with unemployment approaching 9%, employers cutting back on health care benefits, and rising premiums and co-pays, it is becoming even more difficult for patients to pay for their medications.
"As providers, especially in these economic times, we really do have to consider cost as part of our treatment plan--what impact will a recommended treatment have on a patient's life? What are the patient's financial circumstances?" Dr. Mason Turner, chief of psychiatry at Kaiser Permanente San Francisco, said in an interview.
In addition, financially driven noncompliance has become a "huge problem," he said, one that could be avoided if psychiatrists were to devise a reasonable treatment plan with the patient, "There are ways in which we can work with patients by modifying doses. For example, we might be able to get by on 300 mg instead of 400 mg if the price is half, or we can consider a generic that's less expensive."
A lot depends on knowing how much patients will have to pay for a medication, which might not be as easy as it seems, said Dr. Lee H. Beecher, a psychiatrist in a cash-only private practice in Minneapolis. Providers can call local pharmacies to find out the prices of the drugs they commonly prescribe, or they check Costco.com, which lists retail prices for drugs, or online at WalMart, which offers a list of $4 refills.
For patients with health insurance, the final cost might be shaped by copays, formularies, generic substitutions, prior authorization requirements, and Pharmacy Benefit Manager policies that require a patient to "fail [less expensive drugs] first" before a prescription for a higher-cost alternative is allowed.
"Patients and doctors need to know the details about what is covered by the insurance before the prescription is written and before the patient leaves the office or hospital setting," Dr. Beecher said.
And ignorance of those details comes at a steep price, he added. "Patients frequently discontinue or alter their pharmaceutical treatments at the retail pharmacy when cost reality hits. This causes poor care outcomes and diminished trust in the doctor-patient relationship."
One solution, both psychiatrists agreed, is to turn to generic formulations to somewhat ease the financial strain on patients with psychiatric conditions. This is an increasingly popular option: according to industry statistics, generic drug sales increased in 2008, even though the use of medications declined in general during that time.
"What the CATIE [Clinical Antipsychotic Trials in Intervention Effectiveness] and STAR*D [Sequenced Treatment Alternatives to Relieve Depression] trials showed us is that older medications, some of which are now available as generics, can be just as efficacious [or have similar side-effect profiles] as the newer ones," Dr. Beecher said.
And yet the availability of reliable generic drugs varies greatly by drug class. Nearly every psychiatrist has had the experience of seeing patients do well on a patented drug, only to decline when they are switched to the generic.
Generic drugs are permitted by the Food and Drug Administration to have a 5%-10% difference in bioavailability, compared with a patented drug. That can be enough to have an impact on both efficacy and side effects, both experts agreed.
In some cases, psychiatrists are turning to the older, less expensive predecessors of today's front-line drug choices to improve patient compliance over the long term in an effort to keep chronic psychiatric disorders under control.
One side effect of the economic downturn has been a shift in the patient-provider discussion around medications that patients see advertised on television, Dr. Turner said. Until recently, patients would request, even demand, medications by name after learning about them from advertisements. …