ULTIMATELY, YOU CONTROL YOUR DRUG COSTS
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You are the ultimate determinant of your drug cost. In this age, visits to the physician are frequently requests for medication. If your satisfaction with the physician depends on whether or not you are given medication, you are applying pressure against your own best interest. If you go to a physician because of a cold and request a “shot of penicillin,” you are asking for poor medical practice. Penicillin should infrequently be given by injection, and it should not be given for uncomplicated colds. Your physician knows this but may give in to your pressure.
The most frequently prescribed medications in the United States, making up the bulk of drug cost, are not scientifically important medications. Instead, they are tranquilizers, minor pain relievers, and sedatives. These prescribing patterns arose, in large part, because of ill-advised consumer demand. You can decrease the cost of medications by using some of the techniques above; you can eliminate them almost completely by decreasing your pressure to receive and utilize medications which you do not require.
REDUCING COSTS AT THE PHARMACY
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The pharmacy is another crucial factor in your drug expenses. For the most part, the pharmacist no longer weighs and measures individual chemical formulations. Much of the activity in the pharmacy consists of relabeling and dispensing manufactured medication. Medication is thus usually identical at different pharmacies; you should choose the least expensive and the most convenient. Comparison shop. Often discount stores will offer the same medication at significantly lower prices. 1£ a considerable sum of money is involved, you should compare prices by telephone before purchase. If a pharmacy won’t give you price information over the phone, don’t go to it.
Unfortunately, even though your physician writes a prescription by “generic” name rather than brand name, the pharmacist is not required to give you the cheapest of the equivalent alternatives. Often, the pharmacy will stock only one manufacturer’s formulation of each drug. Thus, even though your physician has been careful to allow the pharmacist to substitute a less expensive preparation, the pharmacist may not do so because only a more expensive alternative is in stock. There is no way to detect this problem except to get direct price quotes from different pharmacies.
The majority of pharmacies charge a percentage markup. Their pricing is determined by the wholesale price, multiplied by a fixed profit figure. A sliding scale may be used, but profit is largest on the largest sales. Other pharmacies work on a specific charge per prescription. These pharmacies take the wholesale price and add a constant fee. With a small drug bill, you will be better with the percentage mark-up formulas. If you are buying a significant quantity of expensive medication, application of the one-time fixed charge may be less costly. Knowledge of these problems and aggressive comparison shopping is essential for the consumer to control costs.
YOUR PHYSICIAN CAN SAVE YOU MONEY ON DRUGS
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Your physician plays a maj or role in the cost of drugs by choosing the drugs to be prescribed. For example, if you have an infection due to bacteria, you may be given tetracycline or erythromycin. Tetracycline costs about three cents a capsule, while erythromycin costs about twenty-five cents. If you are given a steroid prescription for asthma, at the physician’s option this may be prednisone at two cents per tablet or methylprednisolone at twenty cents per tablet. Medically, such drug choices are between agents of similar effectiveness. If your physician prescribes a drug by its trade name, in most states the pharmacist must fill the prescription with that particular brandname product. The brand-name product frequently has a cost many times that of its “generic” equivalent. Does your physician know the relative cost of alternative drugs? Many doctors do not.
The drug-prescribing habits of different physicians can be divided into two groups: the “additive” and the “substitutive” prescribers. With an “additive” physician, each visit you receive a medication in addition to those which you already have. With a “substitutive” prescribing physician, the medication you were previously taking is discontinued and a new medicine is substituted. Usually, the “substitutive” practice is advantageous to your health as well as your pocketbook.
Most of the time, medication can be taken orally. The common reason for requiring medication by injection is the physician’s uncertainty that you will take the medication as prescribed; by injecting it, the medication certainly has been taken. As a thoughtful and reliable patient, however, you can assure your physician of compliance with an oral regimen. Taking medication orally is less painful, less likely to result in an allergic reaction, and far less expensive. There are exceptions, but you should seek oral medication when possible.
If it is clear that you must take a medication for a prolonged period, ask the physician to allow refills on the prescription. With many drugs it is not necessary to be charged an additional physician visit just to get a prescription written. Under other circumstances, the physician may wish to examine you before deciding whether the drug can be safely continued or is still required. Ask your physician if refills on the prescription are permitted. The careful physician will ensure that you fully understand each drug that you are taking, the reasons you are taking it, the side effects which may possibly arise, and the expected length of time that you will be taking the medication. A medication schedule will be arranged during the day so that it is convenient as well as medically effective. 1£ the program is confusing, ask for written instructions. It is crucial that you understand the why and how of your drug therapy. Do not leave the physician’s office for the pharmacy without understanding your medications.
Reducing Your Medication Costs
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Legal drugs are a multibillion dollar industry. Your contribution to this industry is largely voluntary. The size of the contribution is determined by your illness, your physician, your pharmacy, and yourself. Drugs are life-saving, dangerous, curative, painful, pain-relieving, and easy to misuse. Also, they are basically poisons. Drugs interact with other drugs causing hazardous chemical reactions. They have direct toxic reactions on the stomach lining and elsewhere in the body. They cause allergic rashes and shock. They are foreign chemicals with severe toxic effects when taken in excess. Under some circumstances they probably cause cancers, and some drugs decrease the ability of the body to fight infections.
If you do not receive a prescription or a sample package of medication from your physician, consider this good news rather than rejection. Prefer to take the fewest possible drugs for the shortest possible time. When drugs are prescribed, take them regularly and as directed, but expect that your medication program will be reviewed, thoroughly, every time you see your doctor.
Most drugs are given as “symptomatic medications,” that is, they do not cure your problem, but attempt only to give some relief for the symptoms of that problem. If you report a new minor symptom every time you see your physician, and urgently request relief from the symptom, you will probably be given additional medications. You are unlikely to feel much better as the result of the extra medications, and you are nearly certain to function at a lower level as a human being. Unless you have a serious illness, you seldom should be taking more than one or two medications at a time. Perceptive observers have argued that the present practice of using drugs to control symptoms is only a temporary phase in the history of medicine
FREE CLINICS AND SURGERY CENTERS
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SHORT-TERM SURGERY CENTERS
Recently a number of facilities specially designed for surgery which requires only a short stay (overnight at the most) have appeared. Obviously such surgery is minor and the patient must basically be in good health. Since such centers are able to avoid some of the overhead of a hospital, they often can charge you less for the use of their facilities. But, since they do not have the capability to handle difficult cases or complications, you should use them only when the procedure is truly minor.
CONVALESCENT FACILITIES
Nursing homes and various types of rehabilitation facilities provide for the patient who does not require more expensive care but cannot be adequately managed at home. These facilities range from abysmal to superb. In the best circumstances, with dedicated nursing and regular physician attendance, a comfortable and homelike situation for the patient can accelerate the healing process. In other cases, disinterest, inadequate facilities, and minimal care are the rule. Before suggesting or accepting referral to a nursing home facility, visit the facility or have a friend or relative visit it for you. In the convalescent setting, your comfort with the arrangements is essential.
FREE CLINICS
In many areas of the country, “free clinics” have developed. In some cases, they have appeared because the general medical care in the community has been poor. In others, clinics have developed to deal with undesired pregnancies, drug use, and venereal disease. These clinics are high in idealism and usually short in money. Sympathetic care from sensitive individuals is the rule. Facilities will be limited, but considerable thought will have been given to those services included, so that relatively little is lost.
These clinics provide care for many who would not find it available elsewhere. However, the financial instability and the political ferment of many free clinics make their continued existence uncertain; these clinics come into and go out of existence with regularity. Free clinics do not present any challenge to organized medicine but serve to remind it of its inequities. In most cases, they deserve much broader community support than they receive.
It will be worth your time to investigate the various medical facilities in your area. If you can, visit them and ask questions. “Is there emergency care?” “Is there always a doctor on duty?” “What are your payment arrangements?” Then choose the facilities that will best meet your needs.
Emergency Rooms
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The emergency room has become the “physician” for many patients. Patients who cannot find a physician at night, or who don’t know where else to go are coming to emergency rooms with increased frequency. The typical emergency room is now filled with nonemergency cases. Trivial illnesses which could have been treated with the aid of this book, routine problems more easily and economically handled in a physician’s office, specialized problems which should have been seen at a time when the hospital facilities were fully available, and true emergencies are all mixed together. Even though the emergency room is not designed for the purpose it now serves, it does a surprisingly good job of delivering adequate care.
However, there are major disadvantages to an emergency room as the sole medical contact. Emergency rooms make little or no provision for continued care. In the emergency room you will usually be seen by different physicians. The emergency room physician will attend to the chief problem reported by the patient but seldom has sufficient time to complete a full examination or to deal with underlying problems. While simple x-ray facilities are available, procedures such as gallbladder studies and upper G.I. series are arranged with difficulty. Thus, evaluation of a complicated problem is not well handled by the emergency room. When a true emergency occurs, patients with less urgent problems are shunted to the end of the line. You cannot estimate with any certainty how long it will take you to be seen in an emergency room. Emergency room fees, because they support equipment required to handle true emergencies, are higher than those of standard office visits. Emergency room services are not always covered by medical insurance, even when the policy states that the costs of emergency care are included. With many policies, the nature of the illness governs whether or not it is covered. You may end up paying a large bill if you go to the emergency room with a sore throat.
The smoothly functioning emergency room is a dramatic place and provides one of the finest examples of a service profession at work. Using the procedures outlined in this book, you can use this valuable resource appropriately
Know When To Use the Hospital
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The hospital is expensive. It is not home or hotel. It saves lives and it takes them. It must be used and it must be avoided. To manage these contradictions, the need for hospitalization for you or your family must be carefully considered in each instance. Don’t use the hospital if services can be performed outside the hospital. The acute general hospital does acute general medicine well; it does not do other functions well. Don’t use the hospital for a rest; it is not a good place to rest. It is busy, noisy, unfamiliar, and populated with strange roommates. Its nights are punctuated with interruptions, and it has an unusual time schedule. It has many employees, a few of whom are less thoughtful than others. Don’t use the hospital for the “convenience” of having a number of tests done in a few days. It does not provide tests in the most efficient manner; indeed, most laboratories and x-ray facilities are not open on the weekend, and special procedures may require several days just to be scheduled. Many have urged that we have a system of “hcptels,” which provide lodging at minimal cost, allow for efficient test performance, and are appropriate for periods of rest and minimal activity. A number of experiments along these lines are underway. Until more appropriate facilities are available, however, use the acute hospital with great reluctance. A century ago, the Hungarian physician, Inaz Philipp Semmelweiss (1818-1865J, noted that both infants and mothers delivering at home fared better than those in the hospital and that the existence of often fatal “childbed fever” was one of the risks of the hospital. This problem, due to poor hygiene in the delivery rooms, has long since been corrected. But in our
present age, new evidence suggests that for many conditions home treatment may work better than treatment in the hospital. For example, treatment for minor heart attacks at home has been reported as possibly better than treatment in a hospital. It is apparent to most hospital visitors that the crisis atmosphere of the acute hospital does not promote the calmest state of mind for the patient. Many therapeutic features of the home cannot be duplicated in the hospital.
Right Hospitals
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The private or community hospital is the most common hospital facility in the United States. These hospitals are usually nonprofit, and contain from 50 to 400 beds. Sometimes they have been financed with funds from doctors practicing in the area. More frequently, nonprofit organizations aided by government funds for hospital construction have financed the facility. The quality of care in these institutions is largely dependent upon the physician in charge of your case. Relatively few physician actions come under serious review. There is not always a physician in the hospital around the clock. Nevertheless, private hospitals usually give personalized care of high quality. The hospital is quiet and orderly. In the great majority of cases facilities are adequate for the care required.
Public hospitals include city, county, public health service, military, and Veterans Administration hospitals. These hospitals are generally large, with from 500 to 1000 beds. They have permanent full-time staff, and physicians are present in the hospital at all times. Usually, they have a “house staff,” with interns and resident physicians available around the clock. As befits their larger size, they offer more services, and frequently have associated rehabilitation units or nursing homes. Activities in the public hospital are more visible, and the efforts of each physician are scrutinized by others. The quality of care you receive depends upon the overall quality of the institution. The presence of interns and residents may pose some minor inconveniences to you as a patient, however, their presence is an excellent guarantee of good care. The physician-in-training has patient care as his or her primary responsibility, and is not greatly involved with office practice and administrative tasks.
Many public hospitals have the reputation for providing service to E poorer economic class. Within the community, they are often perceived as offering substandard service. Usually, these accusations are grossly unfair While not always quiet and orderly, and often not physically attractive these hospitals give dependable and excellent care. When available, they should be seriously considered by individuals in all economic classes. The teaching hospital is one associated with a medical school. Teachin~ hospitals are large, with a range of from 300 to 2000 beds. These hospitals always have interns and residents and additionally have medical students on the hospital wards. They have superb technical resources, and it is here that the most extraordinary events of medicine take place. Open-hearsurgery, transplantation of kidneys, elaborate nurseries for the newborn, support for management of rare blood diseases, and other marvels are all available here. Dozens of people may be concerned with the wellbeing of a particular patient. Crucial medical decisions are thoroughly discussed, presented at conferences, and reviewed by many personnel. On the other hand, the quality of personal relationships at teaching hospitals is variable. Many patients feel that they are treated in an impersonal way, and that their laboratory tests receive more attention than their human and social problems. Since these institutions are on the frontier of medicine, there is a tendency to emphasize the new and elaborate procedures, when older and more modest ones might have served as well. With the inexperience of some members of the care team, there is a tendency to order more laboratory tests than would have been ordered for the same condition in a private hospital. The sick patient is sometimes confused by having to relate to a large number of doctors and students. Medical educators are concerned with such criticisms, and have moved to correct some of the problems. However, some excesses of technological medicine still occur in these institutions.
Right Medical Facility
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A wide variety of medical facilities are available to prospective patientshospitals, emergency rooms, convalescent homes, and clinics. There are choices for most tastes and for the satisfaction of most individuals. It’s important to know the facilities in your area and to make your choices before you need the services. To select the best facilities, you will need to understand the terms “primary,” “secondary,” and “tertiary” care. Primary medical care is provided by a physician at the office or at an emergency room or clinic. It is care which may be obtained by a patient without the referral of another physician. It is often called “ambulatory care” or “out-patient care.” Secondary care is that afforded by the typical community hospital and the physicians involved may be specialists or subspecialists. As a rule, access to this care requires the referral of a physician. Much secondary care is “in-patient” or hospital care. Tertiary care includes special and extraordinary procedures such as kidney dialysis, open-heart surgery, and sophisticated treatment of rare diseases. This type of care is found at university affiliated hospitals and regional referral centers. When you select a medical facility, you want close primary care with good access to secondary care. Tertiary care is often a great distance from your home, and may never be needed during your entire lifetime.
UNDERSTAND AND ADHERE TO YOUR DOCTOR’S PROGRAM
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First, insist on understanding the importance of the medication and the instructions. Secondly, consider whether following the instructions poses any special problems. Third, adhere to the agreed program. Fourth, if medication remain’s after the course of therapy, destroy it. You must understand the instructions given to you. If you are confused, ask questions: “Could you go over that again?” “I don’t understand what this medication is for.” “Do I really have to be treated in the hospital?” “How much will this cost?” “Are there any risks to this drug?” Ask yourdoctor to write out the instructions. Understand the importance of each drug or treatment.
In some instances it does not matter if you take the medicine regularly; in these circumstances the drug gives only symptomatic relief and should be discontinued as soon as possible. Be sure that you understand whether it is or is not necessary to continue the medication when you feel well.
Consider the entire prescribed program. You may have difficulties not known to your physician. Perhaps you have trouble taking a medication at work. Perhaps you anticipate trouble with a prescribed diet. Perhaps reasons unknown to your physician prevent your undertaking the recommended activity. If more than one medication has been prescribed initially, it may be more desirable for you to take them all at once. When such questions arise, ask in advance. Frequently, if you raise these questions with your physician, your treatment program can be modified so that you can feel more comfortable. The keynote is honesty.
Don’t say that you will do something which you know you will not do. Express your worries. After an agreed program has been prescribed, follow it closely. If you notice possible side-effects from the program, call the physician and inquire. If side-effects are serious, return for examination. Make a chart of the days of the week, and the times when medications are to be taken. Note on the chart when you take the medicines. Don’t look on this as an insult to your intelligence; this practice is universally used in hospitals by trained personnel to insure that medication schedules are maintained accurately. At home, you and your family are the custodians of your health. Do not take this task more lightly than it is taken by professionals.
When pills remain at the end of a course of therapy, flush them down the toilet. There are multiple hazards with a medicine chest containing old prescription medicines. Every year, children and adults die from taking left-over drugs. Children take birth control pills, adults brush their teeth with steroid creams, and the wrong medication is taken because another bottle was thought to be in hand. If you give your leftover tetracycline to your children with their next cold, you are probably not aware that you may cause mottling of their teeth. If the same tetracycline becomes outdated and is subsequently used, you are probably not aware that dangerous liver damage may result. When a new illness occurs, the situation is confused if you have already taken left-over medications. Sometimes it will be impossible to make an accurate identification of a bacteria by culture or the clinical picture of the disease may be distorted. The doctor-patient encounter is your most reliable protection against serious illness. Value the opportunity for such attention, utilize it selectively, and follow to the maximum extent possible the instructions you are given.