Greed — for lack of a better word — is good. Greed is right. Greed works. Greed clarifies, cuts through, and captures the essence of the evolutionary spirit. Greed, in all of its forms — greed for life, for money, for love, knowledge — has marked the upward surge of mankind.
— Gordon Gekko (played by Michael Douglas) in movie Wall Street
From time to time our pharmacy receives an order for Vitamin K tablets to treat a patient with a high INR (International Normalized Ratio). This is an urgent care drug: Vitamin K reverses the anti-clotting action of warfarin. Any delay in treatment can be very dangerous. Currently, only one oral Vitamin K product– Mephyton 5 mg tablets–is available to treat patients who have ventured into high or very high INR values while taking warfarin. This product costs about $56 per tablet. The product’s price has increased dramatically over the past several years, reportedly from about $9/tablet to the current $56/tablet.
Despite being an acute or urgent care drug, Mephyton is not kept in stock at some pharmacies. In my area, none of the independent or chain stores stock it. This means that there could be difficulty and delay in getting the medication to a patient in need.
Every pharmacy has tens of thousands of dollars of insulin in their refrigerator and hundreds of thousands of dollars on their shelf at any given time. Cost alone is not the reason the medication is not being stocked. While many medications are expensive, they don’t remain on the shelves for long—the inventory regularly is sold and replaced with fresh stock. In contrast, Mephyton is a much slower moving item. Our pharmacy, for example, has dispensed 26 Mephyton tablets in the last five years. The product is only available as a package of 100 tablets, and that means a single bottle would last 5 years or until it expires, whichever comes first.
It is not unreasonable to ask why the manufacturer only offers this medication in bottles of 100 tablets. A typical pharmacy would not use 100 tablets over the course of several years. I do not know the answer to the question, but one would have to speculate that greed, in the form of profit, is a motivation.
I won’t complain about the cost per dose of this medication: we started by stating that greed is good. The nature of this medication, which is only use for short term acute therapy in a few patients, is a reasonable justification for its current price point. Here, greed is about being able to maintain a niche drug in the marketplace. But I would add the Thriving Pharmacist’s corollary to Mr. Gekko’s statement: good greed is balanced greed.
Here, we need something to balance out the greed for profits. Something to balance the high cost of the medication with the best interest of the patient and their providers. The practice of selling the product only in bottles of 100 misses the mark. It has the potential to jeopardize patient safety and reduce access to this life-saving medication.
Each pharmacy has their own way of dealing with this greed imbalance. One local chain pharmacy, for example, has a regional central fill location where they have product in stock. Using this strategy they only need to maintain a single bottle to support dozens of their regional pharmacies. This is an imperfect solution as there may be significant delay getting the medication to the patient. In our case, we have moved away from using the tablets as our source for Vitamin K. We ask the prescriber to write for the injectable form of the medication to be administered orally. The injectable is no less expensive, but it is available in packages of 10 units. In this way, we are able to stock the medication and simultaneously minimize the risk of expiration or dead stock.
Pharmacies work hard to care for their patients. We are greedy—we have a greed for care. That sometimes means finding ways to counter unbalanced greed. Sometimes the cure is a greed of innovation and creativity. The greed for care. Greed, yet another way pharmacists can Make Every Encounter Count!