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.