I'm not going to pay a lot for this sigmoidoscopy

Should docs be bargain hunting on behalf of the health system when choosing how to prescribe? It's a time thing

By Joshua Karpati

"How much is it?" is every consumer's mantra. Whether shopping for clothes, cars or waffle irons, everybody wants to get the best deal possible. The question is, should doctors be shopping around for the same kind of bargains when it comes to prescribing meds or procedures?

One recent study tried get to the bottom of that very question. Dr Michael Allan, professor in the University of Alberta Department of Medicine, surveyed family physicians in BC to find out how accurately they could estimate the costs of treatments they prescribe. The results, published in the February issue of Canadian Family Physician, are forceful: over 70% of doctors were off the mark by more than 25% in their estimates. These figures mirror findings from other studies worldwide, and they aren't unique to GPs — specialists have the same difficulties.

"Doctors don't want to be the gatekeepers of the medical system," says Dr Allan. "They don't want to make value judgments tied to money." He takes great pains to stress that doctors are not to be faulted for gaps in their knowledge. Indeed, the structure of the Canadian health system makes accurate pricing information both hard to come by and difficult to interpret.

According to Dr Allen, formularies and other prescribing limitations are established with lightning speed, and can very restrictive: "Government is interested in the quickest way to save costs. But you end up with both patients and physicians frustrated." He feels that other mechanisms need to be pursued. "We know that doctors want cost information. Studies have shown that they will modify a prescription with such information."

IN THE TRENCHES
Dr Mark Frobb, a pain management physician in Vancouver, thinks doctors are keen to have access to cost information so they can get a better perspective on the care they provide. But he's not too optimistic about the practicalities of actually getting that info out to the people on the front lines. "I am not at all surprised by these results," he says. "Our focus in training has always been to focus on care, with costs being secondary. It behooves doctors to find out the costs of treatments, but that is a tremendous amount of work." He stresses the nature of the dilemma doctors face: "The medical landscape changes so rapidly, it is simply information overload to try and keep track of the changing costs of medications and studies."

Dr Allan agrees that sometimes it's simply a time thing. "If doctors took an hour a day from their personal time to read one journal article, by the end of the year they will have caught up on only 5% of new information."

He also makes the point that resources available to doctors aren't always helpful. The Compendium of Pharmaceuticals and Specialties (CPS), for instance, has significant input by pharmaceutical companies, who may have a vested interest in not listing prices alongside the medical profile. This is true particularly for new drugs that sometimes offer little clinical benefit yet cost many times more than generics.

To Dr Allan, a reasonable solution would be for a disinterested party — like a government funding agency — to provide cost information to the doctor when they order the drug or procedure. "This would merely provide numbers — it would not be directive or intrusive," he says. He also advocates what he calls 'academic detailing' to counterbalance the so-called 'industry detailing' of drug treatments. He gives the example of diuretics, used successfully to treat hypertension, which are much cheaper than newer drugs. He sees a role for government to keep doctors continually up to date and help them choose treatments that incur fewer costs — as long as there's no clinical compromise.

Dr Frobb still harbours concerns about the clinical promise of this kind of advice. "I doubt if patterns of practice will change," he says. "Physicians are already aware of the importance of generics, and recognize that often new medications need time to figure out their worth."

While there seems to be consensus over the value of doctors having a better understanding of costs, it remains to be seen whether it will have any effect on prescribing patterns.