Nine months ago I saw a new patient, a delightful 86-year old male. His past medical history included lymphoma many years ago, a stroke five years ago, dyslipidemia and hypertension. Medications included aspirin, a generic statin, and a non-generic ARB-HCT combination, which he had been on for years. He lived alone with a lot of support from his loving and attentive family. The patient looked great. I refilled his meds and checked a renal panel and lipids. Results were normal.

About three months later, the patient and I received one of those notes from the pharmacy benefit manager suggesting a switch from the ARB combo to generic lisinopril HCT. This would “save the patient $432.19” a year. The patient called: Could he switch? Sighing, I fixed what wasn’t broken, wrote new 30 & 90 day Rx’s and asked the patient to schedule an appointment to recheck his blood pressure on the new medicine.

Now, I’m not a brand-namer. According to my EHR, 80%+ of my prescriptions are generic; many of those are from the $4 list. I do wonder sometimes if my diabetics are eating Cheetos in line at the grocery store pharmacy waiting for their $4 metformin since they always come back for appointments a few pounds heavier. But I digress.

At the follow-up appointment the blood pressure was up. Medication? Diet? There was a trace of ankle edema. The patient felt a little tired. Sighing, I rechecked creatinine: up just a bit. Sighing, I stalled for a few weeks.

At the second follow-up, the BP was up a bit more, concerning with a history of CVA. No edema, but the patient was still tired and had a new non-productive cough at night.  He was very worried about a recurrence of the lymphoma. Sighing, worried about an ACEI-related cough I ordered a chest x-ray (normal) and increased the HCT just a little (with a new 30-day Rx). I checked a blood count and repeated the renal panel (CBC normal, Cre back to baseline).

At the third follow-up the  night-time cough gone, but he complained of a new daytime cough. The blood pressure was still too high. Sighing, I raided the sample closet for the original ARB and handed over a one month supply plus a 90 prescription if the cough disappeared. It did. At the fourth follow-up, blood pressure was back to baseline.

At this point, thanks to all that cost savings, this 86-year old had four office visits, a chest xray, labwork x2, a confusing mess of 30 & 90 day Rx’s, and you guessed it, was back on the original medication.

The PBM shows a cost-savings because, in fact, the patient was on a generic for a few months. The radiograph, the lab work, and all those office visits don’t show up on their bottom line. In the end, the patient is going to pay the extra $432.19 for the medication (and after all brouhaha isn’t interested in trying generic losartan).

Who underwrote the cost of all those office visits, labs, etc. ? All that money-saving?  Sigh, dear taxpayer. Those very real hundreds of dollars are on our bottom line. The patient has Medicare.

Victoria Rentel is a family physician.

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