Another family called this week to ask if I could change their daughter’s asthma prescription to something cheaper. After looking into their insurance plan’s formulary, there really wasn’t anything cheaper. Every inhaled corticosteroid (which is the first-line medicine recommended to prevent asthma attacks) was expensive – even the generics. This family has to either find a less expensive way to purchase the prescription, choose to leave their child undermedicated, or pay over $300 per month for an asthma preventative medicine. Of course if they don’t give this medicine they risk ending up in the ER in the middle of the night. ER’s are expensive and if it’s a needed trip, it means their child is suffering.
Insurance companies make it hard.
On one hand insurance companies want patients to take the medicine appropriately to decrease long term costs of disease management. They even remind doctors to consider certain medicines if a patient has certain diagnoses and prescriptions haven’t been filled or if follow up appointments haven’t occurred.
On the other hand, they’re pricing many medicines out of reach for many families.
Transparency is a goal for healthcare, but it isn’t there, as Dr. Melissa Welby explains.
What can you do?
Check your formulary
When shopping for new insurance look at the formulary if anyone in your family is on a chronic medication. You will have to talk to an insurance company representative since formularies aren’t publicly displayed anywhere and they’re specific to your plan. This isn’t foolproof because formularies change on a regular basis, but at least learn what they currently have and what your costs would be.
Before doctor visits where you know you’ll be getting refills, check your formulary to see if it has any changes. You can usually log into your insurance company’s website to see your plan’s information.
See if you qualify for Patient Assistance Programs.
These are programs run by drug companies and other organizations that give free medicine to people who can’t afford to pay for them.
You can also do an online search for “patient assistance program” along with the medicine name.
Look at GoodRx and WeRx to search local pharmacy cash pricing with their coupons. This doesn’t give the cost that your insurance will allow, but you can see how much it would cost with cash and compare to insurance cost. Sometimes it’s cheaper to not use insurance but see if the coupon will work with your insurance and compare costs.
These can be used by anyone regardless of income or insurance plan. See MoneyCrashers for a nice summary on how discount cards work and when to use them.
You often can’t use insurance when you use the discount card, so you have to look at your deductible and calculate if it’s better to pay more until you meet your deductible and then get things inexpensively/free or if saving the money but not contributing to your deductible is better.
These cards can be used to help buy over the counter medicines (with a prescription) as well as prescription medicines. I think you can even get cards for your pet prescriptions.
To find drug discount cards, look at NeedyMeds, RxAssist, GoodRx, WeRx or the drug company’s website. I find it easiest to search the drug name and coupon together when looking for discounts.
I have a love-hate relationship with discount cards.
If people can’t otherwise afford a prescription (name brand or generic) then a coupon might help them purchase a needed medicine, but we all pay in the end.
Coupons are offered by manufacturers because they increase the sales of brand-name drugs by 60% or more by reducing generic sales. These programs increase drug spending by $30 million to $120 million per drug (and this study is several years old- coupons are increasingly being used so this might underestimate current spending).
Coupons can help people afford medicines, at least temporarily, but they increase insurance costs overall. If you use your insurance plan with the coupon, your insurance company pays more than they would if you purchased a generic, and they pass that cost on to consumers.
The money you spend doesn’t apply to your deductible if you don’t use insurance. Then insurance companies get off without having to pay for your medicines despite the fact that you pay them monthly to help cover your healthcare. I guess the good news is that if you don’t use insurance it doesn’t increase next year’s premium. But they might see you as “high risk” if you don’t fill recommended prescriptions, so that still might affect costs in the end.
Talk to your doctor.
Of course, it all starts with the prescription itself.
When your doctor is writing the prescription, openly discuss cost concerns. Ask about brand vs generic substitutions in the same class of medications that might be available.
We cannot know your specific formulary, but we can try to help you find the cheapest option. Electronic Health Records sometimes link to insurance formulary information to give an idea of which tier a medication is on. I find this works some of the time. Sometimes it isn’t accurate. People still get to the pharmacy and suffer from sticker shock when they’re told the cost. This is why I think it’s so very helpful if you find your formulary before even going to your appointment. It can save a lot of back and forth at the pharmacy if we have the costs at the appointment.
If you get to the pharmacy and cannot afford the medicine, be sure to let your doctor know! We want to help but we can’t if we don’t know the issues.
Healthcare is available at many locations, such as in the medical home (primary care office), at a specialty clinic, in a hospital or a surgery center, freestanding urgent cares, pharmacy based urgent cares, emergency rooms, telehealth companies, school health clinics and more. Convenience care is what I use to describe the care people desire here and now, when it’s convenient and where it’s convenient.
There are places that are best suited for one issue and others suited for other issues. Sometimes people choose a location based on what’s convenient at the moment, not necessarily when and where they will get the best care. This usually isn’t going to make much of a difference, but it can have implications of varying consequences. Convenience care is not equal to the best care, and sometimes not even equal to good care.
The one about the restaurant
My family likes to go to Primary Restaurant for great food. We know the food is high quality and the chef takes special care to make everything just right with healthy ingredients. The staff gives great service, always making sure we have what we need. Because there’s always room for improvement, they encourage quality development and the restaurant staff works to make things right to the best of their ability if a problem is identified.
But one night we decided to go to Convenience Cooks. We were hungry and Convenience Cooks was on the way home.
Were we starving to death? No. We had food at home we could have eaten, but Convenience Cooks was, well… convenient. Their menu was limited compared to what we are used to, but we were able to order something that was decent.
While we were waiting, I decided to call Primary Restaurant to see if it was a good choice or if we should leave and go to their restaurant. They said since I made the choice and was already waiting, I should just stay at Convenience Cooks.
The food wasn’t the quality we were used to, but we ate it. I had second thoughts at the end of the meal, so I called the Primary Restaurant to see what they thought. The staff who is usually so helpful wasn’t of any use helping me decide if what we ate was good for us or not.
Since none of us felt satisfied and left still hungry, I feel like Primary Restaurant should deliver food to our home, but they refused. They said we should go to Primary Restaurant to eat if we want their food. Why? I already paid Convenience Cooks and had most of a meal there.
Weeks later I get a bill from Convenience Cooks and am surprised about the cost of convenience, so I call Primary Restaurant to see if it’s usual for Convenience Cooks to bill added fees. Again, they said they couldn’t do anything to help with the bill. For a Restaurant that is usually so helpful, I feel like they are dropping the ball because they won’t help with anything that was done at Convenience Cooks. It’s like they don’t have any responsibility for what I eat elsewhere.
The one about specialists
In another scenario, you really want a good BBQ. Primary Restaurant specializes in All-American food, but they don’t offer slow-cooked BBQ, so they refer customers to BBQ-R-Us.
BBQ-R-Us is busy and requires reservations. Since you are used to same day seating at Primary Restaurant, you ask if they can get you preferential seating at BBQ-R-Us. After several phone calls back and forth with staff at each location, you realize you can be put on a waiting list, but no one was able to change your initial reservation.
When that time finally comes, you enjoy the ribs, but leave with questions. Instead of asking the BBQ specialists, you call Primary Restaurant to ask about how the ribs were prepared. You’re disappointed to hear that they can’t give details about the BBQ recipes and tell you to call BBQ-R-Us.
Even later you call Primary Restaurant to complain about the bill you got from BBQ-R-Us. You were surprised that the creamy corn was extra and they charged a seating fee. Again, Primary Restaurant isn’t very helpful in discussing the bill from BBQ-R-Us. They refer you back to BBQ-R-Us.
now change the names
Most people can see just how crazy it is for a restaurant to “fix” the problems with quality, cost, or service at another restaurant, yet many (MANY) people want their primary care physician to do just that after trips to convenience urgent cares or regarding specialist referrals. The scenarios above are based on real phone calls about medical care. These phone calls are not only time-consuming and costly for medical offices, but they’re also frustrating for the people on both sides.
Convenience Cooks = Urgent Cares
I’m sure I’m not alone when I get frustrated at the number of calls asking me to give an opinion of treatment received elsewhere, or to fix a problem that wasn’t fixed at an urgent care. I’m glad that patient families feel so comfortable with my office that they call to ask for help, but if I am not a part of the evaluation, I can’t help.
It’s not that I’m holding a grudge or trying to be mean, but I really can’t help. If I didn’t see the patient or at least have access to the medical record of the visit and know the provider well enough to understand their practice style, I have no idea what was really seen and done.
If you call my office because your child is having a problem with a medicine someone else prescribed, we will tell you to call the place that prescribed the medicine. We cannot manage what someone else prescribed. Often we hear that “they’re not open yet” or “they don’t do phone calls, they want us to come back.” Sorry. We will want to see your child before we treat him for this issue. You can bring him in or you can follow-up with the original prescriber.
On a similar note, if a patient sees someone else in my office, I can look at the medical record documentation. I know the people I work with well enough to know what they typically say and do, and along with their written plan I can usually offer assistance if they’re not available. Sometimes even then I will want to see a patient because symptoms change.
If someone outside my office sees a patient, I really don’t know what the level of exam was, the experience of the provider, or the specific details of the visit. Urgent cares are getting better at sending a summary of the visit to the primary care provider, but we still don’t receive any information a significant percentage of the time. Other than routine general advice, I can’t really say much about the issue. I cannot change or refill another provider’s order. I cannot order labs or x-rays based on another provider’s assessment. I believe that this is not good care and I would prefer to see the patient if they need advice or a change in the treatment plan from me. And I certainly can’t do anything about the bill from another provider.
Many problems seen at urgent cares can wait. I know it’s easier to get your child in tonight so they can maybe go to daycare/school tomorrow, but many of these things are viral and just take time. Even if it’s strep throat and they start an antibiotic at 8pm, they can’t go to school in the morning. If you would have called my office before going to the urgent care (or looked on our website for advice), chances are the issue could have waited until office hours by using some at home treatments to make it through the night.
The cost savings of staying out of an emergency room or urgent care can be substantial with many insurance plans. And my office would be available to help answer any questions that arise from that visit. (Note: sometimes when the symptoms change we still need to see a child again, but we are more likely to be able to help over the phone if we were the ones who saw the child than if they were seen anywhere else.)
There are now some urgent cares that are actually cheaper in dollars because of insurance contracts. I think this is a very short-sighted plan on the part of insurance companies and in the end will cost more in dollars and health complications. They are trying to save money by contracting with these urgent cares (or are merging with them). I worry that fragmented care will in the end increase costs because they won’t have access to a patient’s medical chart. Increased numbers of tests and prescriptions are often seen at ER/UCs compared to primary care offices because they don’t have a means to follow-up like the medical home does so they cover all the bases rather than take the watchful waiting approach that PCPs are able to take. At urgent cares patients will not have the benefit of seeing the same provider each time, so they will never develop the important doctor-patient relationship that can help if and when anything chronic develops.
BBQ-R-Us = Subspecialist Referrals
As for specialist referrals, I know it’s hard for people to wait for appointments, but I really can’t get people in any quicker than a schedule allows. If it is a real emergent or urgent need, I can talk to the doctor to see options, such as admitting to the hospital so they can be consulted, or having someone go to the ER, where they might stop by to see the patient. Usually it isn’t really that urgent from a medical standpoint, and waiting for the appointment is just what happens in the specialist world. I’m not saying that’s a good thing, it’s simply reality. Please don’t beg me to call them to get you in sooner. I cannot invent time and I can’t alter their schedule. Despite what the scheduler tells you, if the primary care doctor calls the specialist, the specialist rarely can get the appointment changed. I’ve done this frustrating scenario many times– often when I really want the child seen sooner than scheduled. Unfortunately it usually doesn’t significantly alter the appointment time. It just wastes my time and the time of the specialist.
After your appointment I cannot tell you if the treatment plan they propose is the best for your child. Once I refer, it’s usually because it is out of my knowledge base and needs specialist care. I can learn along with patients, but I rely on the specialist to know the latest and greatest in their field and they can give better advice than I can. I also don’t like to “step on toes” if I refer. If they are driving the bus, they need to drive. Back seat drivers can cause problems on the road. Let them drive the bus. If you really want another opinion, you’ll have to ask another specialist.
Expect higher fees any time you use a hospital based facility, whether it’s for an office visit, a lab, or a procedure. They not only have charges for the physician’s time, but they have facility fees to cover the costs of running the hospital.
The primary care physician cannot change the charges incurred at any other clinic or hospital. We recommend researching costs prior to care, but we know that this is very difficult unless you know exactly what will be done at every visit. We cannot tell you what another physician will do… I can’t even predict what I will do at a visit if you call me ahead of time. If your child has a fever and cough, I might send you home with at home treatment instructions without any expensive tests if the exam supports that. I might order labs or a CXR, prescribe a medicine, or admit your child to the hospital for treatment if the findings support that.
We try to help by keeping a list of all our most common charges in the parent book in each exam room, but that doesn’t help plan before the visit. It only tells the maximum that will be charged, not the actual amount that will be the patient responsibility after insurance adjustment and payment. I understand how frustrating medical costs can be, but I can only help with what is in my control. Changing how our billing and insurance system works is not in my power. I can only play by the rules.
Every year at this time, I think about how our kids are managed when they become sick. Not only what we do to treat symptoms, but how, when, and where patients get medical advice and care. During cold and flu season kids get sick. A lot.
We are a busy society. We want things done now. Quickly. Cheaply. Correctly. Resolution so we can get back to life.
Illness doesn’t work that way.
Most childhood illnesses are viruses and they take a few weeks to resolve. There’s no magic medicine that will make it better.
Please don’t ask for an antibiotic to prevent the runny nose from developing into a cough or ear infection.
Don’t ask for an antibiotic because your child has had a fever for 3 days and you need to go back to work.
Don’t ask for an antibiotic because your teen has a big test or tournament coming up and has an awful cough.
Antibiotics simply don’t work for viruses. They also carry risks, which are not worth taking when the antibiotic isn’t needed in the first place.
Urgent cares are popular because they’re convenient.
Convenient isn’t always the best choice. Many times kids go to an urgent care after hours for issues that could wait and be managed during normal business hours. I know some of this is due to parents trying to avoid missing work or kids missing school, but is this needed?
Can it hurt?
Extra tests = Extra costs
Some kids will get unnecessary tests, x-rays, and treatments at urgent cares and emergency rooms that don’t have a reliable means of follow up. They attempt to decrease risk often by erring with over treating.
The primary care office does have the ability to follow up with you in the near future, so we don’t have to over treat.
Urgent cares outside of your primary care office don’t have a child’s history available.
They might choose an inappropriate antibiotic due to allergy or recent use (making that antibiotic more likely less effective).
It’s easy to fail to recognize if your child doesn’t have certain immunizations or if they do have a chronic condition, therefore leaving your child open to illnesses not expected at their age.
We know that parents can and should tell all providers these things, but the new patient information sheets in my office are often erroneous when compared to the transferred records from the previous physician. Parents don’t think about the wheezing history or the surgery 5 years ago every visit.
It’s so important to have old records!
Records in one place
Receiving care at multiple locations makes it difficult for the medical home to keep track of how often your child is sick.
Is it time for further evaluation of immune issues?
When should you consider ear tubes or a tonsillectomy?
If we don’t have proper documentation, these issues might have a delay of recognition.
Not all locations are good with kids
Urgent cares and ERs are not always designed for kids.
I’m not talking about cute pictures or smaller exam tables.
I’m talking about the experience of the provider. If they are trained mostly to treat adults, they might be less comfortable with kids.
They might order extra labs or x-rays that a pediatric trained physician would not feel are necessary.
This increases cost as well as risk to your child.
Drug choice and dosing can be complicated for clinicians not familiar with pediatric care.
We have been fortunate in my area to have many urgent cares available after hours that are designed specifically for kids, which does help. But this is sometimes for convenience, not for the best medical care.
As previously mentioned, cost is a factor.
I hate to bring money into the equation when it comes to the health of your child, but it is important, especially with the increasing rates of high deductible health insurance – you will feel the burden of cost.
Healthcare spending is spiraling out of control.
Urgent cares and ERs usually charge more.
This cost is increasingly being passed on to consumers. Your copay is probably higher outside the medical home. The percentage of the visit you must pay is often higher. If you pay out of pocket until your deductible is met, this can be a substantial difference in cost. (Not to mention they tend to order more tests and treatments, each with additional costs.)
What about the walk in clinic at your primary care office?
Many pediatric offices offer walk in urgent care as a convenience for parents who are worried about their acutely ill child.
If your doctor offers this, the care given is within the medical home, which allows access to your child’s chart. All treatments are within your child’s medical record so it is complete.
Staff follow the same protocols and treatment plans as scheduled patients, so your child will be managed with the protocols the group has agreed upon. Essentially primary care pediatricians have a high standard of care and want your child to receive that great care in the medical home as often as possible.
There are more and more telehealth options offered by insurance companies and physicians. This is a new area that has exciting potentials, but I’m concerned about inappropriate treatments. It can be a great tool to follow up on ongoing issues, but is not appropriate for many routine earaches, sore throats, and other issues that require an exam and/or testing.
I know it’s tempting to call in to get a prescription for a presumed ear infection or Strep throat, but think about how those diagnoses are made and remember that overuse of antibiotics increases risks to your child.
So what kinds of issues are appropriate for various types of visits?
(Note: I can’t list every medical problem, parental decisions must be made for individual situations. For a great review of how to determine if it’s an emergency, see Reliable keys to identify a medical emergency from Dr. Oglesby at Watercress Words.)
After hours (urgent care or ER- preferably one for children):
Difficulty breathing (not just noisy congestion or cough but increased work of breathing)
Injury (including but not limited to bleeding that won’t stop, a wound that gapes open, obvious or suspected broken bone)
Pain that is not controlled with over the counter medicines
Severe abdominal pain
Fever >100.4 rectally if under 3 months of age or underimmunized. (There is no magic temperature we “worry more” if an older child is vaccinated.)
Walk in clinic (or appointment) at your primary care provider’s office:
Vomiting and/or diarrhea
Any new illness
Issues better addressed with an Appointment in the Medical Home:
Follow up of any issue (ear infection, asthma, constipation) unless suddenly worse, then see above
Concerta is a long acting methylphenidate used to treat ADHD successfully in many kids and adults. It has a unique time release system that makes it preferred over other medications and difficult to recreate. Sadly, there are once again companies that are trying to substitute for Concerta. Generics for Concerta may not be equivalent to the real thing.
I feel like I’ve been through this before.
Two of my most-readblogs (from my old blog) were about generic forms of Concerta available in 2013-14.
The FDA had allowed companies to manufacture and sell tablets that were not the same as Concerta. People across the country noticed the change immediately.
I started seeing patients who had been well controlled on Concerta for a long time who suddenly were not able to focus, were more angry, and had other focus and behavior problems.
No advance warning
Initially I had no idea there was a new generic, but one mother sent me a picture of the new pill and I knew instantly it could not be the same.
I hope the newly approved versions work better than the previous editions, but am worried not only because they don’t use OROS technology, but there are several new versions coming to market and each could be different.
Original generic rumors
I have heard that the previously available OROS generic (made in the same factory as the name brand Concerta and the same exact pill but with a different label) will no longer be available.
If this is true, options will be to pay for the name brand or go with a new version of the medicine.
What makes Concerta unique?
Concerta is the branded formulation of methylphenidate HCl Extended Release that has a unique time release system.
This time release technology is called OROS (osmotic controlled release oral delivery system).
Unlike many slow releasing medications that are released as the capsule parts dissolve, the OROS capsule doesn’t dissolve.
There is a little active medicine that is released immediately and then the medicine is slowly released through a small hole in one end of the capsule.
You can tell if you have the OROS tablets if they have a small dimple in one end:
The pill works like a pump, pulling in water from the intestines, pushing the medicine out of the tube slowly throughout the day. This allows for a consistent drug release. See this photo from Medscape:
The new generics
The same active ingredient (methylphenidate) is used in the new pills. I have heard that at least one version of the pills is round, so I know they don’t use the OROS system.
The package inserts do not specify what type of delayed release they will use.
I find it very frustrating that each of the package inserts (Trigen, Impax) appear to be nearly identical to the one for Concerta (including the initial US approval date of 2000, which is not correct for this form).
Older warnings, including a contraindication in those with tics, has been found in newer studies to not be a contraindication.
The fact that they did not push to remove it makes me wonder if they did not want to have to change other parts of the document. Figure 1 and Table 6 are identical with the exception of changing the word “CONCERTA” to “methylphenidate hydrochloride extended-release” and Trigen added an easy-to-read table format.
This makes me wonder if they were somehow able to get permission to make their new tablets based on Concerta’s data, not their own.
We’ll see how it works in people who have previously taken OROS methylphenidate ER. Sadly, one version might work better than another, so you will have to keep track of which brand you are using.
What’s good about the new generics?
If it’s true that the currently available generic OROS form of methylphenidate ER is no longer going to be available, it’s good that there will be other options to help keep costs down.
Sometimes insurance companies prefer branded products. It’s all how they contract the cost.
If you don’t know how to use your insurance company’s prescription formulary, you should learn. Also check out GoodRx for pricing information.
Will it work?
One might work as well (or better) than the OROS formulation in any individual. You won’t know until you try it.
One benefit I am excited about if these work:
The Trigen version is available as a 72 mg tablet.
The original Concerta is not able to be made at that strength. You can see from the photos above that the pills get bigger with increasing dosages, and the OROS system has limits to how much it can hold.
For people who need 72 mg, they must take two of the 36 mg OROS tablets. Since patients pay by the pill and they need 60 pills/month instead of 30, this can be quite a bit more expensive.
What should you do if the pills change
Check each bottle when you pick up new medicine and ask if you can return unused tablets if they don’t work for any reason.
Keep track of what each pill looks like and the brand (which should be on the label) so you know which versions work and which don’t.
Talk to your kids about how they think and feel on and off their medicine – some will be more in tune with themselves than others.
Keep in touch with teachers as the pills change so you know if there are school-related issues you’re not seeing at home.
If the pills don’t work or have new or worsening side effects:
Talk to your HR representative who deals with the insurance company.
Call your insurance company directly. Send them e-mails and snail mail.
Ask your physician to write a letter on your behalf.
In each of the above situations, include why your family member needs the OROS technology. Give examples of how it works better than the other extended release methylphenidates and why the amphetamine class of medication failed (if tried).
People were able to get the FDA to look into the issue the last time a different tablet was substituted by submitting complaints to MedWatch.