A lesson in Math

I was never very good at math. I barely survived my pre-med requirement for basic calculus. Although I don’t use any calculus in my day to day clinical life, I get by with my basic arithmetic skills and trusty smartphone calculator.

Infectious diseases is a great field in medicine. There’s often a clear association between causative agents and diseases. For example Helicobacter Pylori (H Pylori) is a common infection found in the stomach that’s associated with a lot of bad stuff if not treated properly. Fortunately, there are treatment regimens involving some common antibiotics that make this condition very treatable.

Recently, I saw a case of H. Pylori that made me question those basic math skills that helped me survive 4 years of medical school, 3 years of residency and 6 years of attending life.

My general understanding of the concept of “addition” was as follows.
1+1 = 2.

This case of H Pylori that I’m about to reference totally rebuked my basic understanding of this equation.
The case taught me 1+1 doesn’t always equal 2. It’s often quite more than that.
Perhaps there are advanced theories in math in which 1 +1 doesn’t equal 2. Such advanced concepts are beyond my pedestrian physician mind!

Ms. Anita Smith (name changed) was a 40 year old woman with no medical insurance and numerous chronic illnesses. She came to our resident clinic already diagnosed with H-Pylori. It was recommended she complete one of the several 3 drug regimens needed to eradicate this bacteria. Unfortunately, she hadn’t started the treatment because she couldn’t afford it. This was surprising because I recalled that the medications (bismuth, metronidazole and tetracycline) were old generic medications.

When the resident and I looked into the price for these medications, each individually appeared to cost about $15-25 dollars. Based on our basic math skills, we didn’t expect this to cost more than $75.
We were shocked to find out Ms. Smith was charged $700! She politely refused this treatment.

We investigated this further and found out she was prescribed a tablet that combines all three medications.
A combination tablet has many advantages. For a hearty organism like H Pylori, a combination pill improves adherence to the regimen and eradication rates. That’s great except for the ridonkulous price!

Is it justified to charge $700 for 3 medicines that individually cost a total of $75?
Granted if she had insurance, she would only have a co-pay. In that case the insurance company is likely getting charged an exorbitant fee to carry the drug on its formulary.

It’s understandable when a new drug is developed from scratch and after a long FDA approval process, a company attempts to recoup those costs and also profit from it. But taking old drugs and mashing them together, marketing it as something new and marking up the price amounts to highway robbery.
This deceitful gimmick is unfortunately an all too common tactic that further drives up the cost of our healthcare system.

And that is how I came to learn that generally speaking, 1+1 =2.
In the healthcare and pharmaceutical world, 1+1 does not equal 2, but often much more than that.


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