Thread by @tjwebbmd

About 6 years ago a patient told me they picked up their medication after our last visit, even though it cost over $200 and they had to borrow money from family to afford it.

The medicine was extended-release Nifedipine. It should have cost about $14.

The patient told me, with some hesitation or reluctance, "I'd like to switch to something less expensive if possible. I know you have to make your money somehow, but I just can't afford this medicine."

I'm not sure how it happened. I probably selected the brand name instead of the generic in the EHR by mistake. And then the pharmacy, by design or just not catching the error, failed to offer a cheaper generic equivalent.

And the patient was left to assume that I was prescribing her an expensive med so I could pocket my share. I was shook. I could explain to the patient that I didn't make any money off of her prescriptions; literally 0 cents. But for her the damage was done; that money was gone.

I did explain, and I apologized, profusely, for the error. And then I decided it would never happen to another one of my patients again if I could help it.

Ever since then, I've always ended any visit where I prescribe a medication the same way:

"None of the medications I've prescribed for you today should be expensive. I think they should each cost about $____, and I've printed coupons for the ones that aren't on the $4 list. If any of them are more expensive than you expect, please don't buy it; call us instead."

I end every visit that way, with modifications if the patient has insurance or doesn't, or if one of the meds actually is expensive. I have similar speeches for imaging, consults, and procedures. Before I schedule a follow-up, I ask how expensive their co-pay is to come see me.

I honestly can't imagine doing less. Our system is so deeply broken, one of the things our patients need most to get something like equitable care is our help navigating the barriers the system puts in their way.

If we had a truly fair and equitable system, built on helping people instead of making money for folks who view them as a profit opportunity and don't actually contribute to their care, I could save all of those speeches.

Then maybe I'd have time to finish all of my charts.