AMA Journal of Ethics^®

Case

Mrs. Michaels has been under treatment for hypertension for several years. She started with a well-known, brand-name drug, which effectively reduced her blood pressure. She has a steady full-time job and some employer-sponsored health insurance that includes a prescription benefit. The prescription co-payments, however, have increased dramatically, especially on brand-name drugs. On several visits, when her blood pressure was high, Mrs. Michaels told Dr. Bennett, her physician, that she had postponed getting her prescription filled for several weeks because she didn't have the money at the time. Her salary barely covers her urban living expenses, food, and transportation to her job.

Because Mrs. Michaels cannot afford to take the brand-name drug all the time, Dr. Bennett has prescribed several generic versions, as each came on the market. Unfortunately, none reduced her hypertension effectively, so she is again using the brand-name drug. One day, after another increase in her blood pressure, Mrs. Michaels told Dr. Bennett that a co-worker of hers takes the same brand-name hypertension drug. The co-worker gets a month's supply of 40-mg pills for the same co-pay that Mrs. Michaels is charged for her one-month's supply of 20-mg tablets under the same prescription benefit policy. Mrs. Michaels asks Dr. Bennett whether he will prescribe the 40-mg tablets under the pretense that it is a one-month's supply. She will split the tablets in half, so that she gets her prescribed 20 mg a day and the prescription lasts for 2 months. "You and I will know that I only take ½ tablet a day," Mrs. Michaels says to Dr. Bennett. "But the pharmacy will think that I am taking one tablet a day and getting a one-month supply." She adds, "That's the only way I can take this medicine every day, all year long. Otherwise, I have to skip it about half the time."

What should Dr. Bennett do? When trying Mrs. Michaels on generic drugs, he was able to offer her samples, but, of course, he cannot continually supplement Mrs. Michaels' prescription with drug company samples.

Commentary 2

This clinical case presents physicians with one of the most difficult challenges of patient care—how to ensure your patients' access to needed medical services and treatment. In this specific circumstance, an insured patient with prescription drug reimbursement coverage comes to a physician asking for assistance in paying for her prescription medication. The patient's "solution" is for the physician to write a prescription for double her prescribed dose, thus allowing her to pay for a two-month supply on a single co-payment.

Paying for high-priced prescription drugs is an increasing problem in the United States. According to a recent national survey, almost 3 in 10 people say they have not filled a prescription because of the cost; one-quarter say they have given up other things to buy prescription drugs for themselves or their families; and 1 in 10 report having to curtail basic necessities, cutting down on food, for example, to pay for prescription drugs.¹ The circumstances of this case are certain to become more common for physicians and their patients.

As with most challenging clinical ethics cases, it is oftentimes easier to say what you shouldn't do, and more difficult to map out a course you would follow in addressing the pressing need at hand. First, a physician should not write an erroneous prescription purposely, even if his or her intentions are good. Beyond the potential legal consequences of such actions, a physician undermines key foundational ideals that define the medical profession—honesty and truth telling. Even if one considers such actions to be an immediate remedy to this specific problem, it cannot serve as a long-term solution because the patient is likely to require other costly medical treatments. The physician may well be in a similar situation in the future, when the patient suggests less "benign" solutions—falsely coding a diagnosis, perhaps, to get coverage on a medical test. If the ethical prescription in this case is to not write an erroneous prescription, then what should Dr. Bennett do?

Based on the information provided, all other therapeutic options seem to have been exhausted. Assuming this to be so, resolving this case revolves around who will pay for the expensive but needed medication. According to the pharmaceutical industry, more than 3.5 million patients received prescription medications through patient assistance programs in 2001.² These programs, which are administered by individual drug companies, offer eligible patients, typically low income individuals who do not have health insurance, free access to prescription drugs. Mrs. Michaels is unlikely to be eligible for such programs because she has health insurance that includes prescription drug benefits. Despite that, it is clear that Mrs. Michaels is better off than most people who have no health insurance at all, and herein may lie the solution to this case.

First, Dr. Bennett must be confident that Mrs. Michaels understands the importance of treating her hypertension and the health consequences of not managing it adequately. Oftentimes, patients fail to understand the necessity of controlling their high blood pressure because it is a disease that typically has no symptoms. Second, all of us make tradeoffs in how we spend our financial resources. There are certain things we must have, such as food, shelter, and medical care, and other things that we would like to have. This is typically not a topic of discussion between patients and their physicians, but I believe that it is important in this specific case. If Mrs. Michaels understands the medical necessity of treating her hypertension, then it is rational for her to pay for certain needs by forgoing certain "wants" that she could live without. This solution is based on the assumption that Mrs. Michaels, who is employed and has medical insurance, can make such financial tradeoffs. If, indeed, she cannot, she may be eligible for drug company patient assistant programs. The solution has broader implications, though. We should all take greater personal responsibility for our health and health care, regularly assessing what life changes and sacrifices we are willing to make to prevent illness and treat it when it occurs.