Dr. John Spangler has been a family physician in Winston-Salem, North Carolina, for 25 years. He knows that the rising costs of healthcare have rippling effects, from insurance premiums to life-saving medications. He recently penned an piece in the Greensboro News and Record about the difficult choices his patients have to make due to the high cost of medications. On this episode of “The Cost of Health,” Dr. Spangler shares how much his patients really have to pay, and how physicians come to prescribe certain medications over other – possibly cheaper – options.

“Should I choose insulin over groceries for my children?” When a patient asked this of Dr. Spangler, there wasn’t much he could do. His patient had to face a hard choice when it came to spending. Do they buy food for their children at the risk of their own health?

Dr. Spangler shares more about the patient, “Mrs. Smith” (not her real name). She’s in her mid-forties, has bad diabetes, and two children.


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“I gave her one of the best of all insulins to help with her diabetes – a long-acting insulin called Lantus,” Dr. Spangler says. “It’s really useful in that it provides insulin for over 24 hours. And she back to me after I had prescribed it a month or two earlier and just said, ‘Dr. Spangler, I can’t afford that insulin. That Lantus was $250. You know, I have two growing boys, and I have to pay the electricity bill, the rent. So, it really came to me choosing between groceries and insulin. So that’s why my blood sugar is 320 today.’”

If you have a story to share about the impact of healthcare costs on your family or business, let us know at michael@fiscalhealthnc.com or on twitter @michaelck.

Dr. Spangler had to choose a different diabetes insulin regimen for her that’s not quite as good, but is affordable. He shares that Mrs. Smith is a hard worker who picks up extra shifts, and is active in her church and in her children’s schools. But on a limited income and minimum wage, that extra $250 for life-saving medication was taking food from her children’s mouths.

It’s frustrating to Dr. Spangler.

“[She’s] someone that really is struggling to do the right thing. She's working. She's trying to provide for her kids. She makes minimum wage -- you see someone like that who is really, really trying and just can't afford to get the best possible care.”

When tax-paying, hard-working families cannot afford medication, charity organizations, lower-cost medications, and coupons can step in as supplements. But that may not be enough to cover the entire bill. Even using drug coupons from companies like goodRX.com, or pharmacy shopping for the best price to save money, the savings aren’t nearly enough. The true problem still lies in the cost of prescription medications, as well as the push for physicians to use certain types of drugs. Dr. Spangler notes that there are deliberate marketing practices made by pharmaceutical representatives, and that there are relationships built between pharmaceutical representatives and doctors.

“Drug companies have a reputation for giving out free samples,” Dr. Spangler says. “But nothing is free. The drug companies are able to do this for two reasons. One: Making the drug itself is not that expensive for them. And two: They're making so much money selling it to people full cost, that they can just give it away.”

The delivery of samples comes with free swag – things like baseball caps, pens, notebooks, stress balls, or cups with the drug name on it. It can admittedly be helpful in rural areas where samples are depended on for care. Patients deserve to know what drugs are available. The problems arise when one drug becomes the only drug available. The price can rise, and the patient will have no choice but to pay it. Unless the next representative comes with a less expensive option, doctors are inclined to stick with what is working.

The trend these days is for doctors’ offices to decline free samples. It’s been shown that doctors who accept free samples can be subtly swayed into prescribing the newest medication, which is often the more expensive option.

“It has been shown that if the drug company gives you a notepad with the drug name on it, or a pen that has the drug name on it, there is a subliminal suggestion to you every time you write a prescription on that notepad,” he shares. “[You think] ‘Oh, that's a choice. That drug is a choice.’ Just by doing that, you are more likely to prescribe that drug. It's a sort of subtle suggestion.”

Dr. Spangler notes that there are probably formal rules about the swag doctors can receive, but he stresses the focus on ethical best practices rather than a law.

“You can actually go to ProPublica and look up your doctor and see whether he or she has received money from drug companies,” Dr. Spangler shared.

Some doctors get a free lunch. While others may have gotten $50,000 for lecturing on that drug.

“It can be eye-opening,” Dr. Spangler continued. “I would recommend patients to go and have a look and see what their doctors have received.”

Dr. Spangler believes that more can be done to help N.C. patients. As do we. The North Carolina Coalition for Fiscal Health wants families to be able to afford both healthcare and groceries.

To listen to this week’s episode, and learn more about the pharmaceutical practices that keep costs high, download our podcast here, or listen to the full interview below.

If you have a story to share about the impact of healthcare costs on your family or business, let us know at michael@fiscalhealthnc.com or on twitter @michaelck.

As our state and federal legislators work to fix our broken healthcare system, it is important that they remember that every regulation, every mandate, can result in costs that require dramatic lifestyle changes and piecemeal healthcare plans for North Carolinians.

Past (and future) episodes of our podcast “The Cost of Health” are available for download. Visit here, or listen and subscribe on your favorite podcast app.


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