Doctors play a dangerous game to find an affordable prescription

Today’s evidence that the nation’s health care system is a mess comes from WBUR, which reports on a “game” doctors are playing now when it comes to prescriptions: Guess the one patients can afford.

Every patient’s health insurance plan varies, and the costs — and so the copays — of a prescription can soar overnight, so there’s no way for doctors to know whether a prescription is “right” for a patient.

Oh, sure, medically it’s comparatively easy to know. But if a patient can’t afford the cure, what’s the point of the exercise?

WBUR documents the game one doctor — Hayward Zwerling — has to now play.

Here’s what happens: Zwerling writes a letter to [patient Larry] Rose’s regular pharmacy that includes a list of insulin brands and doses.

Rose heads to his pharmacy with the letter to figure out the prices of the drugs. He waits at the drop-off counter watching the pharmacist peck away at the keyboard. Each search comes back as “price not available.” Eventually the pharmacist gives up and tells Rose to come back with the actual prescriptions. If the pharmacist has an actual order, he might be able to say how much Rose would have to pay.

Rose retreats to Zwerling’s office. He’s agitated but determined. Rose has been in waiting rooms alongside patients with advanced diabetes.

“I would see people that were missing an eye; I’d see people who were missing limbs,” Rose says. “I need insulin, ’cause I don’t want to lose my feet.”

The game proceeds now with a risky move. Dr. Zwerling writes Rose a handful of prescriptions he can take back to the pharmacy.

“But I’m very cautious about who I’ll give multiple prescriptions to,” Zwerling says. “And if I do that, I’ll write all over them in big bold letters, ‘this or this, not both.’ This would be a catastrophic mistake to take twice or three times the amount of insulin.”

Zwerling is balancing risks: that patients won’t take their insulin because they can’t afford it, versus finding out what they can afford using multiple prescriptions.

“If I end up in court, God forbid,” says Zwerling, “my argument is going to be, ‘I tried to do what I thought was in the patient’s best interest.’ ”

Rose goes back to his pharmacy, this time with his little pile of prescription slips. They help some. He finds out that one medication isn’t covered by his insurance. Another might cost more than $300 a month; the pharmacist can’t tell unless he actually fills, or adjudicates, the order. Rose doesn’t take that chance. He opts for a generic insulin that seems cheap at the time. The price has since tripled.

“So that was a useless exercise,” says Rose, shaking his head.

In all, it takes three doctor’s appointments, two trips to the pharmacy, four or five emails and a couple of phone calls to determine that the only affordable insulin for Rose is a generic that he has to inject twice a day, WBUR says.

It is apparent to anyone who is not (a) employed by a pharmaceutical firm or insurance company and (b) a politician in America that this is insane.

CVS says it has a solution that will give doctors the ability to know the cost of a prescription to a patient based on his/her insurance. But it’s having difficulty partnering with the major electronic health record systems to integrate the tool.

“It will take time,” a spokesman says.

As if patients have the luxury.