Michael D. Lockshin, MD

The New York Times today had an article written by Stephanie Saul entitled THE COVERAGE GAP Avoiding Medicare’s Big Hole. The last three paragraphs discuss the ‘fact’ that many patients are reluctant to discuss the cost of their prescriptions with their doctors. The claim that patients and their doctors do not want to discuss cost of medicines is both incomplete and wrong. Several factors inform both my choice of what to write on a prescription pad and the out-of-pocket cost to the patient: * Different insurers choose as "preferred" prescriptions different medications of the same class, presumably because the insurer has purchased the chosen drug in bulk at discount. Unfortunately, when a physician works with six or more different insurers, keeping in mind which is preferred for which insurer–they are never the same–is difficult and tedious to find out. * Insurers that do have "preferred" prescriptions change their preferences at random, unpredictable intervals, so that a "preferred" prescription in October may have changed when the patient returns in April. * The same problem occurs when a patient changes insurers, as many annually do. * Because of co-payment rules, patients often ask me to write a three-month supply for a medication they need to take for 10 days, the former having no co-payment, the latter requiring out-of-pocket payment. * A patient may speak of the cost of medication at a convenient pharmacy, but the cost for the same medication will be quite different at, for instance, a Wal-Mart on the other side of town. * Some patients clearly have adverse or beneficial responses to one brand of "equivalent" drug but not to another–and are quite explicit in saying so. * New York State has a generic drug prescription law, requiring me to certify by a separate signature that a specific brand is required. If I write a prescription using the easier-to-remember proprietary name and do not sign the box certifying the brand, the pharmacist is required to supply the cheaper generic–or equivalent–instead. Most pharmacists do, so I have to ask my patients on return visit what drug they have been given in lieu of the one I prescribed. * Years of practice have given me a comfort level with some medications compared to others, an instinct, if you will, regarding good and bad things to expect. To use a usual doctor's double-negative: this experience is not irrelevant. The problem is not so much that patients and doctors are embarrassed or unwilling to discuss drug prices as it is that, when all factors are considered, the facts of cost are hard to ascertain. If there is any simple fix, it is to standardize costs and preferences across all insurers and suppliers, so that when I write a prescription I can reasonably predict what will happen next.

A patient with APS recently emailed me with a question about vaccinations for her two small children. Her concern was that her children may be genetically susceptible to having a reaction or could develop an autoimmune condition from their vaccinations. She like the rest of the general public has gotten conflicting information about vaccinations, not only for autoimmune diseases, but other illnesses like Autism as well. And she wanted to know where she could get information about the question of vaccinations and autoimmune diseases. Here is what I wrote her:

There is a Nobel Prize available for the person who can answer your question(s). Current thinking is that lupus (and, by extension, APS) is triggered by a common virus in a susceptible person. The leading suspicious virus is cytomegalovirus (CMV), which causes a mononucleosis-like disease; Epstein-Barr virus (EBV), which causes mononucleosis, is another candidate. There is an extensive medical literature on this topic. John Harley and Judith James, in Oklahoma, have published several papers indicating that the infection likely occurs a decade or more before the disease becomes obvious. You can hunt for these papers at the National Library of Medicine site (PubMed) and search on the terms “Harley J AND lupus” or “lupus AND CMV” or such to find the papers, or, given a day or two, I can compile a list for you.

None of us in my world think of vaccinations as likely virus triggers; on the other hand, if you have no concept of how devastating polio, tetanus, diphtheria, measles, etc. can be (lethal, brain-damaging, permanently disabling) you may underestimate the value of vaccination. If you choose not to vaccinate your children, you rely on “herd immunity”, that is, the luck that others they encounter will be immune and protect them. Loss of herd immunity has resulted in epidemics as recently as this year of these common diseases in fundamentalist communities, Native American communities, and “hippie” colonies in the United States this year, so these diseases are by no means gone.

Bottom line: although your children may have inherited (a degree of) susceptibility from you, they are somewhat protected by their father’s genes; vaccinations are not the things to fear. Rather, common infections, some of which can be prevented by vaccination, are more likely triggers.