how do you expect me to pay for this???

kmoonshine, RN · Jan 17, 2009

I consider this to be a part of my responsibility when discharging a pt. Just yesterday I had a little kid with strep throat and he was actively vomiting. The doc wrote a prescription for an antibiotic and zofran; I quickly looked to see if they had insurance, and they were self-pay. So, I told the doc to reconsider writing a prescription for an anti-emetic that was cheaper (the kid would probably end up back in the ED dehydrated, puking, and with a fever because they couldn't keep any meds or fluids down since they couldn't afford to take the nausea med).

Is it best practice to write a prescription for the newest "top-of-the-line" medication (even though a pt can't afford it)? Or, is it best to write a prescription for a cheaper medication that produces moderate results?

We have to consider affordability in th ED - otherwise, people will end up right back where they started (with us). This is not only bad for the pt, but it drives up health care costs for everyone.

Sometimes, the "best" medication isn't the "best" treatment for the pt.

I like to say to my pts "The doctor had originally written a prescription for a medication that normally costs $120 out-of-pocket - I let the doc know that you couldn't pay that amount, so the doc wrote you a different prescription for a med you can pick up at target for $4...how does that sound?" (it helps to put the before/after cost into perspective).

There are some people who will say that they can't afford to pay anything for their meds - whatever the cost may be (even if its $1.00). Its odd though, because the pt was somehow able to afford that pack of cigarettes in their pocket. Many people are happy to pay for their "wants" but grumble about paying for their "needs".

$4 Drug List (Target): http://www.rxassist.org/providers/documents/TargetGenericsProgramDrugList.pdf

$4 Drug List (Walmart): http://i.walmart.com/i/if/hmp/fusion/genericdruglist.pdf

Midwest4me · Jan 17, 2009

I agree with the suggestion of a referral to a social worker.

KyPinkRN · Jan 17, 2009

i asked the social worker to come up and she suggested ( and i find this dumb) maybe they have a relative they can barrow money from. good heavens i could say that. lol... useless .. i do think our social worker will be laid off next.. she does nothing..

Your social worker needs to get her butt in gear or be replaced. Even if they did borrow the money from a relative, are they going to be able to continue that every month... no! Here in KY we have St. Vincent Depaul, which is sort of like Goodwill. They actually can get some prescriptions drugs at no charge, they have a list of certain drugs just like the $4 programs do, but it really helps. Our social worker actually speaks with the docs discharging the patients prior to discharge to assure that they aren't going to have problems with prescriptions. I really like the way we communicate with each other about that... a few days in advance they will discuss the discharge meds and have a plan already in place for the patient to go home on. No patient has ever had to say to me, on their way out the door, "How am I supposed to pay for this?"

BroadwayRN, ASN, RN · Jan 17, 2009

I hate to be the doubting Thomas in the crowd but do realize that some people are just yanking your chain.

I've heard this from ER patients only to see them leave in a Lexis or light up a cigarette as soon as they get in that BMW.

Some people don't like to spend money on anything that they don't think of as a luxury or a neccessity. We have one frequent flyer who is literally killing herself. She has no insurance and comes in with extremely high BP's and chest pain. She has been given numerous scripts for a generic BP med. $10 for a 3 month supply at several chain stores or $4.00 for a months supply. She says she cannot afford to get it filled. She smokes 2 packs of cigarettes per day.

If I truly thought she didn't have the money, I would give her the money to get it filled.

I realize that there are truly people who have to do without something else essential in order to pay for their prescriptions but I'd be willing to bet that quite a few are just trying to get something for nothing.

Docs I know give samples to their needy patients to keep them compliant and never write them a script unless its for a $4.00 generic.

llg, PhD, RN · Jan 17, 2009

This would be a good topic for a staff meeting and/or a good project for your staff to work on. Your hospital can/should develop some teaching materials/handouts that would guide patients to helpful resources. Staff could also receive some education on the resources available and how they can respond helpfullly in such situations.

You could bring in Social Services, Pharmacy, and Physicians to the discussion to help reduce the costs of meds (generics, automatic referrals to Social Work, etc.). With the economic situation as it is, we all need to be even more aware of this problem and work on ways to help our patients get the meds they need. It's a good time to do some unit-wide or hospital-wide projects on this issue.

So ... speak up ... start the conversation ... volunteer to serve on a team that will address the issue ... and improve the situation for everyone.

Good luck.

Altra, BSN, RN · Jan 17, 2009

i have had this said to me many times. i just don't know what to say , for some reason people think i write the perscriptions and should help them pay for them.

I don't think patients necessarily believe that you write the prescriptions, or that you should help pay for them. They are simply verbalizing their distress and you happen to be the person listening.

Out-of-pocket medical costs are obviously a huge problem for many people. This was the case even before the current recession.

If your social worker is unfortunately as unhelpful as you've indicated, you might have to *direct* him/her with suggestions such as, "Can you please investigate what state prescription programs this patient might be eligible for?" or "What pharma company resources/programs do you have a list of?" Sometimes you have to push.

pagandeva2000, LPN · Jan 17, 2009

I don't think patients necessarily believe that you write the prescriptions, or that you should help pay for them. They are simply verbalizing their distress and you happen to be the person listening.
Out-of-pocket medical costs are obviously a huge problem for many people. This was the case even before the current recession.
If your social worker is unfortunately as unhelpful as you've indicated, you might have to *direct* him/her with suggestions such as, "Can you please investigate what state prescription programs this patient might be eligible for?" or "What pharma company resources/programs do you have a list of?" Sometimes you have to push.

I think that this depends on the population. We deal with immigrants and the poor, many of them are not educated. A great number of my patients do actually believe that they are entitled to free everything. And, they also believe that somehow, I can produce more than I am legally able to because I am a nurse. It is a source of anger that I have to contain daily. I have had patients demand that I give them the $10 out of my own pocket and even to go down to our pharmacy to purchase it myself...I mean, enough is enough!! I have even seen some patients approach our nursing staff in the streets when they are leaving duty to demand that they take a script out of their purse to give them things without even seeing a doctor.

I do believe that out of pocket cost is an issue for everyone and I really wish that there was more that I/we can do, but I can also say with faith that my hospital has done the best that they can. A self pay patient can pay $2 for each medication and obtain glucometer supplies dirt cheap. This is MUCH better than what most of the private hospitals are able to do in my area, and I really believe that there is a level of self responsibility that has to take over for with the patients. Instead of going to McDonalds, or coming in with their Gucci bags (some of our patients are also drug-dealers or girlfriends of hustlers so, they have more access to money on a daily basis than I will see in a lifetime).

Believe me, I am not saying that the needs of these people should be ignored! But, also, self responsibility means to observe the signs of the times. Our systems are bleeding dry! I am actually writing down some of the names mentioned in this thread to render more resources to the patients because I do want to help. I work the late clinics where the hospital social workers have gone and there is maybe one on call one who is swamped with abuse cases. Sometimes, it is easier to be able to give a resource that you know will gain results rather than wait for hours for a social worker to be able to respond. However, if someone can give you a resource where you can pay so cheaply for medications and the money is squandered elsewhere then, well...when does it stop??

Altra, BSN, RN · Jan 17, 2009

Pagandeva2000,

I agree with what you have posted. I responded to the OP picturing the patients I see truly in need of multiple maintenance meds who are routinely discharged without the resources to obtain these meds. Even if all of them are of the $4 Wal-Mart category, $4 x 12 meds is $48 worth of monthly groceries for some. The dingbat social worker at the OP's facility makes me angry.

Believe me, in the ER I see P-L-E-N-T-Y of those who have not and likely will never make the mental connection between the $4 pack of smokes in their pocket and the ability to purchase a month supply of anti-hypertensives. And plenty of those who, on paper, live "off the grid" with no permanent address, no employment, no government assistance and no other *documented* means of support ... but are dropped off at the ER by someone driving a Lexus.

I counsel patients on an individual basis according to my best personal judgement regarding what exactly their difficulty may be. I prod case managers & social workers when they'd rather not be bothered if the patient is a poorly dressed 84-year old who arrived at the ER via EMS and I observe having to call multiple family members to try to obtain a ride home. With others as described above ... sometimes there is way more pyschosocial pathology than can be dealt with in a brief ER visit.

pagandeva2000, LPN · Jan 17, 2009

Pagandeva2000,
I agree with what you have posted. I responded to the OP picturing the patients I see truly in need of multiple maintenance meds who are routinely discharged without the resources to obtain these meds. Even if all of them are of the $4 Wal-Mart category, $4 x 12 meds is $48 worth of monthly groceries for some. The dingbat social worker at the OP's facility makes me angry.
Believe me, in the ER I see P-L-E-N-T-Y of those who have not and likely will never make the mental connection between the $4 pack of smokes in their pocket and the ability to purchase a month supply of anti-hypertensives. And plenty of those who, on paper, live "off the grid" with no permanent address, no employment, no government assistance and no other *documented* means of support ... but are dropped off at the ER by someone driving a Lexus.
I counsel patients on an individual basis according to my best personal judgement regarding what exactly their difficulty may be. I prod case managers & social workers when they'd rather not be bothered if the patient is a poorly dressed 84-year old who arrived at the ER via EMS and I observe having to call multiple family members to try to obtain a ride home. With others as described above ... sometimes there is way more pyschosocial pathology than can be dealt with in a brief ER visit.

:up:I understand. I also want you to know that the response I made to your post was in no way trying to challenge your idea or experience...I was basically piggybacking on what you said based on recent frustrating experiences that I see no change to.

truern · Jan 17, 2009

Out-of-pocket medical costs are obviously a huge problem for many people. This was the case even before the current recession.

I can attest to that!! I've been on long-term disability for the past several months making about half what I made working (and damned thankful to get it!!), but I then pay over $1100/month for COBRA vs the $350/month I paid for BCBS while working. My out of pocket for Rx meds is over $300/month!! I pay $50 a bottle for Lantus that doesn't even last the whole month!!

At least I have an end in sight. I don't know how others do it

Not_A_Hat_Person, RN · Jan 17, 2009

Does the patient live near a Wal*Mart, Costco, or Target? They sell a large number of generic drugs for $4 or $9. Walgreen's sells a 90-day supply of a lot of generics for $9. Stop and Shop is giving out free antibiotics (with prescriptions) until February 1.

Are some of her meds available OTC? Last time my husband had a procedure, he came home with a prescription for Colace. It was available OTC, as docusate sodium, for $4.99.

pagandeva2000, LPN · Jan 17, 2009

Does the patient live near a Wal*Mart, Costco, or Target? They sell a large number of generic drugs for $4 or $9. Walgreen's sells a 90-day supply of a lot of generics for $9. Stop and Shop is giving out free antibiotics (with prescriptions) until February 1.
Are some of her meds available OTC? Last time my husband had a procedure, he came home with a prescription for Colace. It was available OTC, as docusate sodium, for $4.99.

That is true...my girlfriend had to purchase medication for her grandmother. The script was for Nexium, but, the pharmacist told her that OTC Pepsid would also be acceptable. My hospital doesn't give medications that can be obtained over the counter, such as tylenol, vitamins (except prenatals), and colace, to name a few.