Health Care’s Broke: Drug Access
I’ve always found it curious that we spend so much research and clinical time and money on drug treatment, debating which antihypertensive is best, or which chemo combination cures the most people, but quickly gloss over the requirements to get a pill in a patient’s mouth. To take one extreme, consider the following thought experiment: say a researcher develops a cure for cancer and HIV (yes, at the same time!) but that each pill costs $5 million. While the theoretical efficacy of the drug may be 100% at providing a cure, its practical efficacy is near 0%: without money (or more generally, access) for this pill, it cures no one.
Study after study after study has shown that a lot of people skip their medications, and in the US, this is often due to cost. You take someone and say, “Hey, here’s $100, do you want food for the month or medications,” and funny enough, they choose food. Certainly there are other reasons that people do not take their medications–and these affect people in all countries–but patients in the US are much more likely to cite cost as the main reason they do not take their medications.
A few reasons this doesn’t really make a whole lot of sense:
- We pony up and pay for the acute consequences of poorly controlled chronic diseases already. Let’s take my oft-picked-on disease, diabetes. If someone needs a foot amputation, or they need dialysis because their kidneys have shut down, we pay for it. So we wait until they’re super sick and then require a huge investment in resources, but before that, they’re simply out of luck. How is that a good financial investment? How does that minimize costs in our business-run health care world?
- We pony up for acute care which we know saves lives, but not the chronic follow-up care which we know saves lives. If someone has a big heart attack, we throw an insane amount of resources toward that patient: emergency room staff, we often call in a team of cardiologists to go open up a clogged artery, and operate expensive machinery in the process, because we know it may save his or her life. But we take that same patient at discharge, when we have similar data saying that a drug like a beta blocker may save his or her life after having a heart attack and don’t provide the same resources to the patient, even though the beta blocker is a much cheaper intervention.
Yes yes, acute issues are by definition more immediate and often more life threatening, but if we’re providing resources, shouldn’t we provide them on some logical, rational basis or principle?
I’ll touch more on this in some of my concluding posts (which are coming up) but at the very least we should be providing better medication access to patients who have known indications for said drugs. I’ve seen uninsured patients with urinary tract infections who can’t afford their antibiotics and have simply returned to the ED with pyelonephritis (a kidney infection due to an untreated bladder infection) and require IV antibiotics and a hospital stay. It makes no sense for any player in our health care system: the patient, the nurse, the doctor, or even the health insurers, who’re getting billed more from hospitals because the hospitals have to care for the uninsured. We should all be angry, frustrated, and annoyed at yet another example of our health care non-system which, at the end of the day, costs us all more in time and money.
I applaud Wal-Mart, Target, et. al for making a huge list of their generics $4. It certainly makes things much more affordable for many people.
It’s all well and good to make the argument that paying for the small stuff will save us money on the big stuff. But there will be a period (20 years)were we have to pay for both. Are you prepared to make a 20 year gamble that it will pay off in the end? Is there an economist somewhere that has actually run the models to prove that it’s true? Also, the major burden on health care is not from lack of drugs but lifestyle choices and old age. In an ideal world I think that acute and chronic problems should be covered but I don’t want to give up my ability to have my cancer or heart attack treated. Unless everyone is willing to pay during the transition it’s not going to happen.
http://www.waittimes.blogspot.com
Yay for Walmart cheap generics! Unfortunately, my antidepressant is not on the list, but hopefully it will be someday.
Greetings!
Writing from a country sharing similar efficiency of the health system according to Sicko:) I have a few things to share:
1. Here virtually everybody has full health insurance. Hardly anyone pays anything directly at the pharmacist’s.
2. People demand medicines for every possible condition they may or may not have.
3. They tend not to take their medications.
4. Recently I moved and now I work at a general hospital with a large proportion of rural patients. With me I brought my way of writing discarge letters: to everyone treated I recommend physical activity, a healthy diet and other lifestyle changes I think should be made with regard to the original complaint. While most patients say they will change, take pills, reduce weight etc. (some actually will) my colleagues find this thoroughness amusing at least. Especially because I am relatively young. Not trying to complain here but to illustrate that it is us who should change first and then everything else should follow.
5. A while ago I’ve read The Undercover Economist. In it I found an interesting idea of a healthcare system: Singapore (if I recall correctly): everyone there is obliged to put a sum aside every month (it is collected on a special personal account, the sum was calculated on basis of how much an individual would spend on full insurance) and then every wear-and-tear medical bill is covered from that pile of money. Besides that it is compulsatory to be insured for catastrophic events (eg. myocardial infarction). In this system, everyone is aware that the time a physician spends on a patient is of value, that drugs do cost something but it also allows individuals to take individual decisions regarding their health. Namely, if they do not spend their health-care money up to an age they can add it to their pension plan. Or pass it on to children when they die. It seems original. Unfortunately, I did not have had time yet to think it through or at least collect more information on it:) But it does seem to cut visits from those concerned individuals.
Hey BV,
I was not aware of the system in place in Singapore.
It sounds very much like the system I just proposed in my most recent blog post which I put up earlier this week.
I will have to do some googling and read about the Singapore bit.
I will admit your post chagrines me a bit as I have family who have received medical care in Singapore in the past and it never occured to me to ask them about their experiences there.
Thanks for your heads up!
By the way, what country are you currently practicing in?
[...] here I was feeling all smug and proud of myself this morning ,when I came across Graham’s most recent post. Now the post was interesting and all, but what caught my eye was the comments section. Look at [...]
It’s interesting that you think preventive care is cost saving. It is not. It may be cost-effective, but that is entirely different.
It’s also interesting that cost is often cited as a reason for non-compliance, but often it boils down to willingness to pay. Take my soon-to-be doctor classmates who refuse to pay for their asthma medication because it “costs too much” but then go out to dinner five times that week for $50 a pop. I’m not saying $100/month is cheap for everybody, but I AM saying is that those who can pay SHOULD. And they don’t want to either.
@ drsam: it’s Slovenia. Actually, it is amusing how information is sequestered even in todays world. Maybe because computers are unable to process ideas?
There might be SOME who forego the $100 for meds because they need it for food. A good reality check would be if those people were of low BMI and just keeping pace, barely staying ahead of starvation. The truth is that people, when given a choice, will spend their money on what gives them short term happiness, without looking at the future. I would, myself, to some extend. It’s rare that they are foregoing food. I have no way of convincing you, but I personally have zero doubt that many who choose not to spend on their own healthcare have chosen to spend their $$ on IPODs, high end cell phones, clothing beyond the bare minimum for their alleged tight budget, movie tickets etc. My friend is a social worker for the underprivileged with children of special needs and she notes that more than half of her clients have plasma TV’s. Nobody can blame people for choosing what makes them happy. My point is that many who choose not to buy their meds are doing so out of choice , in order not to forego other sources of happiness. I grant you there are some who just can’t afford the $100 and would starve themselves for days to afford it, but that scenario is far from the majority. Now having pointed that out, I agree with you that it would be nice if we all did a better job of getting the proper meds to the people who need it. How do we persuade the patient to value their medication more than they value their non-essentials?