A newspaper report said recently, "Doctors may be losing the battle to control high blood pressure, as stroke deaths begin to rise after a 20-year decline."
The story reported on an American Heart Assn. meeting in Santa Barbara where Dr. Russell Luepker of the University of Minnesota had disclosed a decline in the use of blood pressure medicine among patients tracked in Minnesota.
He thought the rise in stroke deaths was probably caused by the reduced use of medicine, which in turn was at least partly due to a sharp increase in the price of blood pressure drugs.
This is certainly true in my practice. My patients frequently complain to me about the high cost of their medicines. I know they sometimes cut corners and skip taking some medications because they cannot afford them.
Many of my older patients are on blood pressure medications such as Cardizem and Zestril. Both are excellent, and both are expensive. Though they can have life-prolonging effects, they can also have purse-emptying impact. Combined daily doses of both of them, not an unusual prescription, cost $78 a month.
Many patients take multiple medications. I have one whose full monthly retail bill for the medicine that enables her to lead a normal life would be $350. Her HMO pays about half of it, and she pays the rest.
I emphasize to patients that the medications I prescribe are essential to their health. When I can, I give them samples to help until they can afford a new supply.
Arthritis patients often tell me "the pain is back," and when I ask about their medications, reply, "I couldn't afford it." A few weeks ago an elderly woman came into my office complaining of shortness of breath. My examination showed she was suffering heart failure. She confessed that she had not been taking her heart medication. I gave her some samples, and a few days later she was much improved.
Why has medicine become so expensive? Partly because it costs a lot to invent and market a new drug. In 1987 a report from the Center for the Study of Drug Development indicated that it takes 12 years, from synthesis to regulatory clearance, to bring an American prescription drug to market, at an average total cost of $231 million. When a drug finally gets approval, the manufacturer may have only a few years of exclusive marketing left on the patent. Successful medications are quickly copied, with just enough changes to be licensed as new.
The Food and Drug Administration's testing requirements have been blamed for high costs and delays. Recently, the FDA streamlined the process so that new, sometimes lifesaving, drugs can be available to the public more quickly. There is, however, a point of diminishing returns. Many new drugs are highly toxic, and their effects must be known before the public has access to them.
Another factor that drives up the cost of drugs is cost shifting. Volume users of medication pressure the pharmaceutical manufacturers for reduced prices. Any large purchaser of drugs may do this. These purchasers include hospital chains, HMOs, pharmacy chains and the government itself.
The California Medi-Cal program and many HMOs require that the drug companies rebate a portion of their profits from prescriptions used by members of these programs. The loss of income caused by rebates and discounts is shifted to the patients who have to pay retail. The best way to reduce the cost of medication would be to eliminate discounts and rebates so everyone pays the same.
Health maintenance organizations have attracted many patients by including medicines as a benefit. The HMO may require the pharmacist to substitute with a generic drug, or persuade the doctor to allow a similar but less costly medication.
However, generic drugs are not always as good as the brand name equivalents. They are allowed greater variation from stated content than brand names are. This is not important in most cases, but some drugs should not be substituted at all. If a generic product is substituted, it should be from the same manufacturer each time it's refilled, because potency can vary from source to source.
One of my patients complained that her angina medicine had suddenly stopped working. Her newest batch of pills did not dissolve under her tongue as quickly as the last batch. I went to the pharmacy that had supplied the medicine, where I knew the pharmacist. We did a simple experiment. We put three brands of the angina medication in three glasses of water. My patient's regular medicine dissolved more quickly than the new one. We agreed there would be no more switching.
HMOs limit the monthly and annual dollar amounts they will allow for medication. A seriously ill patient may have medication costs far beyond the allowed amount. Patients on fixed incomes may have to face the choice of pills or food.
In the last few years, several scientific studies have demonstrated that reducing necessary medications may result in adverse clinical effects and even hospitalization, especially among the elderly.
Patients who can't afford their prescriptions should discuss alternatives with their doctor. Medication reduction or change must be at the discretion of the doctor and patient, not the pharmacist or the HMO.
If finances make it impossible to buy necessary medications, pharmaceutical companies sometimes provide free medication to the truly medically indigent. The other choice is to apply for aid from Medi-Cal, the California state program that provides medicine and care for the indigent.