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INTRODUCTION

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The rush-hour traffic on the 405 freeway in Los Angeles seemed even worse than usual and Andrew Martin's thoughts began to drift back to his workday and the big construction deal that he had been working on for a month but was now falling through. Suddenly he began to feel a dull, constant pressure in his chest that travelled down his left arm. He took a few deep breaths, but the pressure seemed to get worse and began to feel like it was suffocating him. He pulled off the freeway and drove to the closest emergency room. As a previously healthy 55-year-old man he infrequently saw a primary care provider and did not take any medications. The emergency department (ED) physician said that it seemed like a panic attack, but that he should be admitted overnight to get some tests in order to “just make sure that this isn't your heart.” Although that statement made him even more nervous, Mr Martin's chest pain resolved shortly after arriving at the hospital.

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He spent the night under telemetry monitoring in an observation unit located next door to the ED. The next morning a cardiologist stopped by his bed and told him that based on his blood work (two negative troponin tests obtained 8 hours apart) and his normal ECGs, he was not having a heart attack, but that his cholesterol drawn this morning was found to be high. His 10-year risk of cardiovascular disease (derived from the Framingham risk calculator)1 was approximately 15%, so the cardiologist recommended that he start on a statin. Mr Martin agreed to take this medication and the cardiologist wrote him a prescription for Lipitor (atorvastatin calcium; Pfizer Inc) 40 mg by mouth, once daily. Mr Martin left the hospital and went straight to his closest pharmacy to fill the prescription. When the pharmacist entered the prescription she told him that this medication will cost him $191 each month. Mr Martin is worried about his cholesterol and the fact that the cardiologist told him that he is at risk of having a real heart attack one day, but he thinks back to his failed construction deal and his tight financial situation. “Never mind for now, I will have to come back another time,” Mr Martin tells the pharmacist, leaving the drug store without his prescription.

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Unfortunately, the out-of-pocket costs of medications have led many patients to forgo recommended treatments. Patients like Mr Martin are often not aware that less costly statins exist and they may feel embarrassed about bringing up an inability to pay for this medication with a healthcare provider. Although the majority of patients report a desire to talk to their doctors about out-of-pocket drug costs, only 15% of patients say they have ever done so.2 The discomfort caused by discussing costs is not only common for patients, but healthcare providers as well. In one study, 79% of physicians wished ...

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