I was recently working on an article for Pharmacy Times regarding the use of new software to help predict costs of medications at the point of prescribing by providers. It’s been a problem many are trying to solve, and a number of companies appear to have some promising solutions. In any event, during my background search, I came across an article published in the New England Journal of Medicine back in 1967 titled “Predicting Prescription Prices.”
At the time, I thought, “wow, they’ve been working on this forever!” and requested my library to get the article. Now, the article request took some time, and for those that have made a library request, when it takes more than a week, you know something is up. Apparently, they had to have another library pull up the article from the archives, scan it, and then send it my way. And to be quite honest, it was not what I was expecting.
You see, I thought it would be some viewpoint or related article lamenting the costs of drugs at prescribing, or a review of means to find out prices back then. I was not expecting an article that delved into how racial bias affected drug cost. That’s the rub, I never considered this as a thing, and in all my years of education and training, it was never something that caught my attention. In a way, I have grown up and practiced in an era where such a topic has fallen by the wayside to a certain extent, where most of the people that taught me had themselves been trained in the mid-to-late 90’s, and this was something I never heard about. But to be reminded of it presented some mixed emotions.
But, let’s talk about that paper and the research because I think it presents some methods and results that were surprising. The study was aimed to determine whether race appearance impacted the amount charged for a prescription and if the ownership of the pharmacy was a variable of the cause. They conducted the study in a large midwestern city (I believe it to be Kansas City-based on authors contact information) and included a sample of pharmacies in locations where average family income exceeded $8000, and was below $3000 a year.
Four medical students posed as patients, where “Two were “well dressed” white medical students (white shirt, tie and sports coat), and two were “poorly dressed” Negros (T-shirt, jeans and two day growth of beard.” Ok, so I’m going to pause here, in all my time reading peer-reviewed literature, I’ve never seen the word ‘Negro’ used. That was an immediate sign of the times to me. Getting back to the methods, the students were randomly assigned to visit a pharmacy in their attire and to purchase 100-count of 0.25mg tablets of digoxin (Lanoxin). For those that don’t know, this was a commonly used drug to treat irregular heart rhythms (arrhythmias) back in the 40’s to 90’s and still used to this day, to a lesser extent. It’s a damn old drug.
After the student made the initial purchase for the drug, a student of the opposite race then revisited the same pharmacy one week later. A total of 40 pharmacies were included in the sample. The white students completed 40 visits, while the black students only completed 39 visits, as one student was told: “there was no pharmacist on duty.”
I won’t get into the nitty-gritty of the statistical analysis, but the essence was that the pharmacies were broken down into cohorts, based on neighborhood income (high or low), ownership type (independent or chain), merchandise sold in the pharmacy (basically did they sell drugs only or other additional supplies and goods), and concentration of pharmacies nearby.
The results are telling. There was a statistically significant difference in cost for drugs noted between the two student populations. The least expensive drug store type overall was the chain-drug stores that were in low-income neighborhoods with multiple pharmacies located in the surrounding area — essentially ‘central city chain drugstores. The cost was on average $1.87 for the white students and $1.93 for the black students. The most expensive difference in drug costs? Independent pharmacies in well-off neighborhoods with few other pharmacies nearby. The average price for both populations was $3.19. I am going to quote the next part —
“The most interesting results were those observed in independently owned variety drugstores located in poor neighborhoods with few nearby competitors… At 6 pharmacies in this classification charged the Negro observer more than his white counterpart…The mean price charged was $3.00 to Negro observers and $2.48 to white observers.”
Overall, black students were charged more than their white counterparts 17 times of the total 39 pharmacies they visited.
The author’s discussion was not really anything interesting, glazing over the possible reasons for why the prices differentiated. I suspect this is due to the political climate at the time and editorial reasons. After all, the civil rights movement was going on during the time of this study. Nonetheless, there were a few statements that stood out to me.
“…studies indicated that knowledge of the wholesale price of a drug alone does not make it possible to predict the price paid by the consumer. If the appearance of the purchaser is also an important factor in retail drug pricing in certain neighborhoods, as the present study suggests, another dimension is added to an already hopelessly complex mercantile system.”
It’s incredible that 60 years later we still cannot fully figure out how much a drug will cost at that pharmacy easily, but at least we don’t factor race into the equation at the point of prescribing.
“Neither the patient nor his physician is primarily interested in the inner workings of the pharmaceutical business. They are concerned with purchasing accurately compounded prescriptions cheaply with minimal inconveniences.”
I wonder what the authors would make of the rising drug costs now, and the massive initiatives and concerns are rising from their medical organizations.
“Twenty-three per cent of the time, poorly dressed Negro purchasers were charged at least 15 per cent more than well dressed white purchasers. In every case the Negro purchaser paid more than the white purchaser at small independently owned variety drugstores in poor neighborhoods with few nearby competing pharmacies. Coincidentally, the neighborhoods in which these stores were located were predominately Negro.”
One of the limitations of the study I noticed was that the authors never identified the race of ownership of the pharmacy. Nonetheless, it was a surprising finding to me. Part of me wonders if this helped get chain pharmacies a boost overall as prices were recognized by patients as being more just at such locations and led to their takeoff as well.
I had to take a few minutes to mull the paper over after reading it. During that time, I chanced upon Childish Gambino’s “This is America,” (if you haven’t watched it, I highly recommend it) and I had a rush of conflicting thoughts that made me write this to reflection.
I am proud to practice in an era where drug costs and medical services are not racially based as they were in the past. Anyone that walks into a clinic and gets a medical service will be charged the same. The equality of cost of care has become equal. And yet, I have seen, and the literature continually points out that the level of care and service provided still differs amongst different races. Insurance, availability of healthcare professionals in certain regions, and general practice still differs in different parts of the country. We have come far, and yet still have further to go.
Part of me truly wonders if in another 60 years, when healthcare professionals see our current literature if they will scratch their heads at the complications we face today in providing equal care to all. I can only hope, that in their time, we will have progressed further and that such issues will have passed the majority of humanity by.