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Cash Patient: A Clinical Dilemma

Editor's Memo from August 2012

The headline in my local newspaper read, “Husband is addicted to pain pills.”1 It was a letter to “Dear Annie,” an advice column that has replaced the Ann Landers column. The distraught wife stated her husband takes pills to maintain “his energy level,” but never mentioned whether her husband had pain. The wife’s main complaint was, “He is putting stress on our budget and spends at least $100 a week on these pills.”

Based on the limited information in the column, it was not possible to know whether the husband was an addict or a legitimate pain patient. Regardless, the article points out the growing problem of the pain patient who has no insurance and must pay cash for medication. Does anyone believe this situation won’t worsen? Will the Patient Protection and Affordable Care Act, also known as ObamaCare, help?

I know my recollection is imperfect, but the cost of medications we use in pain practice, which include antidepressants, anti-inflammatory agents, neuropathic drugs, opioids, and even testosterone, have multiplied several-fold in recent years. They have multiplied so much that a cash patient can hardly be adequately treated. I recall not so long ago that medication and laboratory costs combined didn’t exceed more than 10% to 20% of my office fee. Now my fee is paltry compared to the cost of the medication I prescribe. This, of course, has led some patients to suffer and remain at home in bed or on the couch rather than seek employment, training, or a meaningful life.

On the more malignant front, some patients will pay cash for drugs and sell part of the prescription to cover costs. In summary, the exorbitant and growing costs of pain medications are now promoting suffering on one hand and diversion on the other.

What’s to be done about this? The fact is, we physicians are limited, but we can’t ignore this situation. The incessant upward drive of medication cost can be traced to a production and delivery system with too many greedy fingers in the pie. The medication system is overly complex and fraught with regulation, taxation, and an expensive array of manufacturers, wholesalers, and pharmacies. So, just what can we physicians do? For starters, we need to know the out-of-pocket costs that patients are being charged by our local pharmacies. I supply all my cash-only patients with a written list of the lowest-cost generics from the cheapest pharmacy in my neighborhood. This list is my formulary from which to select and prescribe based on what the patient and family can comfortably afford.

It’s no magic answer, but I try to keep the cost of prescription medications down by recommending some non-prescription food supplements and over-the-counter (OTC) preparations. Take a stroll through one of your big retail drug stores and health food outlets. Just as I have done, you will undoubtedly identify a few items that will save your patients a few bucks and even give a little extra comfort. I particularly like the amino acids glutamine, taurine, tyrosine, and phenylalanine to hold down the use of benzodiazepines and antidepressants. White willow bark and fish oil are cheap anti-inflammatories. The neurotransmitter ɣ-aminobutyric acid and the hormones pregnenolone and dehydroepiandrosterone are inexpensive and sold in health food stores. Sometimes they even hold down opioid dosages. There are a lot of OTC topicals including caine-type anesthetics, hydrocortisone, and progesterone (Pro-Gest). These OTC topicals often provide a lot of pain relief for knees, shoulders, feet, backs, and necks. They work particularly well under heat, light, or infrared. Inexpensive infrared devices can now be bought over the Internet for fewer than $30. Additionally, a number of pretty good transcutaneous electrical nerve stimulation devices can be purchased from catalogues or online for fewer than $40.

I now take an inventory of my patients so I know who has to pay cash for medications. All my local pharmacies have been told (“threatened”) that they can’t sell expensive opioids to cash patients, because some of it will likely be diverted. We physicians can’t be bankers or police officers, but we can look out to the best of our ability to protect our patients’ pocketbooks and our communities from diversion. Send us any ideas you may have as I, for one, believe the cost of medication will worsen.

As if outlandish medication costs weren’t enough of a problem, a severe pain patient who can’t afford treatment is a disaster in the making because these patients can’t afford x-rays, laboratory tests, urine and genetic testing, and expert consultations. Any need for paraspinal interventions or surgeries is out of the question. The dilemma is that we physicians are supposed to practice by up-to-the-minute standards and guidelines. This is almost impossible with a cash pain patient. A scary part of this dilemma is that regulatory agencies and malpractice attorneys currently disregard this “inconvenient truth.” For example, I recently reviewed a malpractice case in which a cash patient died because he took a few extra dosages of his prescribed opioids and benzodiazepines with a fifth of whiskey. The malpractice attorney demanded to know why the doctor had not sent the patient to a psychiatrist or addictionist. When informed that the patient had no money to pay for these consultations, the attorney claimed this was “no excuse.” He further stated that the physician should have taken care of the finances.

Let’s call it like it is. The health system, in all aspects, is now so ungodly expensive that cash-paying, chronic pain patients cannot get standard-of-care treatment. The idea that we must reject cash or poor patients, as a lot of parties desire us to do, is a notion to be discarded out of hand. I now place a notice in cash patients’ charts that I can’t possibly be responsible if the cash patient needs surgery, diagnostic tests, or expensive medications. You may wish to do the same. Physicians throughout the ages, however, have accepted their calling to serve the sick, poor, and pained. At many times in history, as now, the physician may not be a popular figure in society for carrying out our mission. What should doctors do? As always, we must do our best to relieve pain and suffering with what resources are available. Even more, don’t apologize.

Last updated on: August 29, 2012
First published on: August 1, 2012