A Costly Prescription: A Doctor’s Dilemma in a Broken System

💊 A Costly Prescription: A Doctor’s Dilemma in a Broken System

In clinical medicine, we’re trained to focus on the science—diagnosing the disease, selecting the most effective treatment, and prescribing accordingly. But what happens when the real challenge isn’t the disease, but the system meant to deliver the cure?

A recent encounter in my general practice made me pause and reflect on something I often overlook: the true cost of the medicines we prescribe, and the unseen burden it places on our patients.

The Patient Who Could Afford It—But Still Got Exploited

She’s a 65-year-old patient I’ve known for years—a respected general manager of a leading company. I’ve been managing her chronic conditions: diabetes, hypertension, dyslipidemia, and early renal impairment. She’s intelligent, disciplined, and financially well-off. In short, not someone who would flinch at the price tag of her medications.

But I was the one who flinched.

As a matter of policy and principle, I always prescribe using generic names. For example, I write Metformin, not the brand name. I do this to avoid pharmaceutical influence and to give the patient freedom to choose an affordable option. In my private practice, I usually stock essential medications myself—purchased wholesale from State Pharmaceutical Corporation (SPC) or State Pharmaceutical Manufacturing Corporation (SPMC) at a fair price.

However, this time, I had run out of stock. I sent her prescription—written generically—to a nearby pharmacy. What came back shocked me.

The Price Tag? Rs. 12,000 for One Month

Here’s what the pharmacy provided:

Empagliflozin – Rs. 2,900

Prazosin XL (2.5mg twice daily) – given at Rs. 5,000

Rosuvastatin 20mg – given in a brand name, costing Rs. 132 per tablet, totaling Rs. 3,920 for the month

That’s nearly Rs. 12,000 for just three medications. I couldn’t believe it. Yes, she could afford it. But is this fair? Is this ethical?

I immediately called the pharmacy and asked if they had any SPC or SPMC equivalents. They casually said yes. On requesting a refund and substitution, the Rosuvastatin brand was switched to an SPC version costing Rs. 42 per tablet—bringing the total for that drug down to Rs. 1,260. That’s a Rs. 2,640 difference—for one medicine, over one month.

Pharmacies First Offer the Most Expensive Brands

That experience opened my eyes. Pharmacies, especially when handed generic prescriptions, often offer the most expensive brand available by default. They don’t present options. They don’t explain price differences. They rarely ask if the patient prefers a state-supplied or more affordable version.

In a country where many families struggle to meet their basic needs, this practice is exploitative.

A Doctor’s Dilemma: What Should We Do?

This incident made me question my own approach. Should I start specifying not just the drug, but the manufacturer or brand? Should I write Rosuvastatin 20mg – SPC brand only? But that defeats the purpose of generic prescribing, which was meant to keep us impartial and patient-friendly.

It’s a real dilemma.

Should we prescribe the best-reviewed brand, the cheapest one, or the safest one—even if it's not affordable? When cost becomes a barrier, how do we balance clinical excellence with financial prudence?

The Bigger Picture: System Reform is Needed

This isn’t just a personal frustration—it’s a systemic problem. Without proper regulation, patients are vulnerable to profit-driven pharmacy practices. There must be guidelines requiring pharmacies to:

• Offer patients a choice between branded and generic versions
• Display transparent pricing for alternatives

• Honour prescriptions using state-manufactured medicines if available

Until then, doctors need to be more vigilant. Because not all our patients are company directors. For some, one month of medication is half their monthly income. That’s not just a clinical problem—it’s a moral one.

Prescribing With Heart—and With Eyes Open

Ultimately, this experience reinforced a truth I often forget: Prescriptions must be patient-centred—and pocket-centred. It’s not just about choosing the right drug for the disease. It’s about choosing the right drug for that patient, in that economic reality.

We may not be able to fix the system overnight, but we can start by being mindful, informed, and advocating for our patients at every step of their healing journey.