The public continues to seethe over the insane cost of prescription drugs, yet it seems no one has been able to do anything about it. Politicians and an angry public point fingers, but unfortunately, at the wrong culprits.

Yesterday, one of my long-term success stories, a delightful Indian woman who suffers from crippling arthritis and devastating dry eye, returned for follow-up after a lengthy visit home. She brought with her a mostly empty bottle of

KETOMAR, a brand name combination of gatifloxacin and ketorolac, which had been prescribed by an Indian eye specialist. Manufactured by Allergan, it is unavailable in the United States, which piqued my curiosity. When I asked her how much it cost, she quickly calculated the currency conversion and said, “about $4.00.” I stared at her in disbelief for a moment as I realized that a bottle of generic gatifloxacin by itself would cost at least ten to 15 times that in the US. Branded Zymaxid lists at almost $200 a bottle on Drugs.com, and that’s after a

discount. So how did American health consumers end up so screwed and who gets the blame for it?

It’s not the prescribers, as the insurance industry would like the public to believe. Most of us spend more time than we should trying to navigate the system to reduce drug costs for our patients. For the most part, it’s not the pharma industry either. When a new drug is introduced, placement at a preferred tier on the insurance formulary is critical. That’s true for existing drugs as well, but oddly, it’s not based at all on the drug’s merits. The real key to a high formulary tier is a massive under-the-table kickback that ultimately raises the price of many drugs to astronomical levels compared with what they could sell for.

The generic drug industry is equally culpable for high drug prices. They quash competition from traditional pharmaceutical companies by bundling multiple drugs across a wide variety of disease states. This results in increased drug retailer profits and decreased insurance company pricing, but it comes at the cost of lower priced, higher quality branded products being essentially blocked from the market.

The systemic dysfunction that results is painfully evident when insured patients can barely afford their insurance, often can’t get medications they need, and usually can purchase medications at 20 to 50% less by using a free discount card like GoodRx than their insurance copay, despite paying exorbitant amounts for their coverage. The bizarre reality is that when it comes to drug benefits, Americans would be better off if they lived in the third world. Eventually, something has got to give.

Arthur B. Epstein, OD, FAAO Chief Medical Editor artepstein@optometricphysician.com