Eye on ethics: Free is a very good price

September 17, 2007

Pharmacists do not begrudge the assistance given to the patient in need, but what happens to the community pharmacist when drugs are given away?

A One U.S. chain has begun providing free antibiotics to patients, regardless of their insurance coverage. The program makes use of very low-cost drugs; the stated value of the retail write-off is $10 to $60. Skipping insurance billing ignores DUR requirements, and the pharmacy staff will run relays behind the counter to provide this "free" benefit. Pharmacists don't begrudge assistance to the truly needy, but giving away drugs to the insured is a marketing technique and carries many implications.

For years, an entrepreneur in Portland, Ore., has used the slogan "Free is a very good price!" as he gives away free pillows and blankets with each set of bedding he sells. At first glance, cutting co-pays and handing patients free prescriptions looks like a marketing tool. But who will benefit, and who will pay the price for this kind of charity?

Inspired by the Asheville project, some large employers have waived co-pays for essential medications and have also hired pharmacists to educate, monitor, and troubleshoot employees' drug therapy. Going way beyond free antibiotics, this benefit design offers a unique opportunity for pharmacists to carve out a direct patient care practice, completely separate from drug dispensing.

Not surprisingly, drug companies are excited about these approaches. Nationally, the rhetoric about drug costs has almost exclusively focused on cutting pharmacy reimbursements and streamlining dispensing; price negotiations with drugmakers were even excluded from the Part D benefit design, despite overwhelming public support. Good R.Ph.s could prove invaluable to insurers who want to control costs, since their expertise in managing drug therapy is unparalleled within the healthcare team.

If free medication alone guaranteed drug therapy compliance, we'd see nearly perfect results with the Medicaid population and other patients who receive drugs at low or no cost. Making this kind of benefit work also requires direct patient care-on site, at the doctor's office or the pharmacy-in tandem with no-cost medication.

Giving away drugs essentially brings another segment of the population along on the slow, steady march toward a national prescription drug benefit. Entitlement programs now provide prescription drugs to Medicaid patients, pregnant women, children, and Medicare patients. Those left behind on this march may find themselves increasingly unable to pay for medication.

Depending on what pharmacy does with this opportunity, giving drugs away can either take another bite out of pharmacy's paycheck and further erode the pharmacist's position in the healthcare system or provide an opening to offer professional services.

As pharmacists who have signed unsatisfactory contracts can attest, giving drugs away can be very hard work. Organizations that buy into the concept of providing drugs free will have to follow up with quality patient education and management, or the only entity to benefit from this deal could be the drug manufacturers. A free bottle of medication could become very expensive indeed.

THE AUTHOR has practiced long-term care and community pharmacy in Oregon for more than a decade and has served on numerous professional and community boards.

Disclaimer: This column highlights ethical situations that often occur in pharmacy practice. It is designed to stimulate discussion on how to deal with these situations and is not intended as legal advice. Pharmacists who need immediate assistance should consult their attorneys, employers, state boards of pharmacy, and state and federal laws.