“Hazardous to seniors’ health.” That could be an appropriate warning label to attach to proposals being made for unlimited prescription drug coverage under Medicare.
President Bush has put forward a modest proposal to cover prescriptions for the nation’s poorest seniors, thereby giving Congress time to consider ways to revamp Medicare to cover prescriptions for all seniors. But some of the proposals under consideration would offer unlimited prescription drug coverage, and experts fear these plans could hurt, rather than help, many seniors.
Dangers of Drug Interactions
Many patients, particularly seniors or semi-seniors, take a wide variety of medicines for heart disease, hypertension, elevated cholesterol, diabetes, obesity, arthritis, chronic lung disease, and other conditions. Many also use non-prescription vitamins and dietary supplements.
All medicines, even the best, have side effects, some severe. The beneficial effects of medication are the ones that treat disease or symptoms. The side effects can make you sick or kill you. Patients must be aware of the delicate balancing of benefits versus risks.
It’s often the case that no single physician or pharmacist–or even the patient– knows all the medications being ingested, injected, or applied by patch, liquid, ointment, or creme. If Medicare is extended to cover all prescriptions, the situation could get worse.
A survey of 1,000 adults was conducted last fall for the American Society of Health System Pharmacists, which represents pharmacists who practice in hospitals and other health care institutions. As expected, the survey found people tend to take more prescriptions as they grow older.
Seventy-nine percent of respondents over age 65 reported taking at least one prescription drug each day, while only 28 percent of respondents age 44 or younger did so. The survey also found that about 8 percent of people entering a hospital—nearly one in 10—don’t report to doctors or nurses what medications they’re taking.
Even when a patient accurately reports his or her medications, no physician can completely understand all the interactions possible when multiple drugs are used. Dr. James Fries, author of the 1994 book Living Well, notes that even simple “antacids can decrease the effectiveness of antibiotics.” A person taking two medications will likely have fewer interactions than a patient taking 10 medications—who will have the potential for millions of drug interactions. No physician can completely understand all the interactions possible when multiple drugs are used.
Diseases interact as well; for example, high blood pressure can cause kidney failure, and kidney failure can exacerbate high blood pressure.
The average American senior citizen takes more than a dozen prescription drugs every year. Millions of complications and interactions are possible. Indeed, Fries estimates that “10 percent to 20 percent of hospitalizations for seniors are the result of drug side effects.”
According to Dr. Miguel Faria, editor-in-chief of the Medical Sentinel, it’s a very real possibility that public policies aimed at improving access to prescription drugs could have the unintended consequence of endangering seniors’ health. An unlimited prescription drug benefit, notes Faria, may “follow the laws of unintended consequences, causing over-prescription of drugs and over-medication in seniors.” He warns that “drug interactions are more severe, particularly in the central nervous system, in seniors.”
Moreover, following the laws of economics, Faria says, “unlimited prescription drugs would increase the demand, in addition to increasing the price, and thus the overall cost of health care.”
Prior Authorization No Answer
In the ongoing effort to protect patients from medical errors, the process called “prior authorization”—getting approval from an HMO prior to getting a prescription filled—is thought to be a useful tool.
But some observers suggest that requiring authorization for every new drug coming to market may be more costly than it’s worth.
According to Debi Reissman, PharmD, president of Rxperts, Inc, a managed care consulting firm in Irvine, California, “While prior authorization helps to curb inappropriate drug use through its sentinel effects, it nonetheless continues to be a problem for all concerned.”
“For the health plan, it is a labor-intensive and expensive process to manage,” Reissman explained. “Many plans quote costs of $10 to $25 per authorization request, with more than 80 percent of the requests approved. For physicians, prior authorization is seen as a threat to their diagnostic and treatment authority; to patients, it is considered interference with their right to receive the best medical care available. And pharmaceutical companies consider prior authorization a process that keeps their products from patients who might benefit from them.”
Prior authorization is a topic of great discussion among state and federal policymakers. Proposals are being considered that would add more regulations to existing codes governing prior authorization. Legislators may require that health plans allow patients to obtain second opinions in an effort to overturn prior authorization denials. Other proposals would require that final approvals/denials be determined by a physician, rather than a pharmacist or technician. Such proposals often further require that denied appeals be reviewed by a physician other than the original reviewer.
“All of these processes will add time and expense to the prior authorization process,” Reissman observed, “even though the majority of prior authorization requests are eventually approved anyway. It thus becomes questionable if the savings actually offset the expenses incurred.”
Avoiding over-medication is key
Fries’ Living Well offers an excellent overview and more detailed guidance on how patients can avoid problems of over-medication. He notes, for example, that “Seniors eliminate drugs from their body slowly and usually need only relatively low doses.”
The good news is that Americans are living longer and better than ever before. Although most of us will ultimately require some type of medication, there is no reason to be medicated to sleep . . . or even death. Prevention is healthier than cure.
Michael Arnold Glueck, MD has written extensively on medical and legal reform issues. Robert J Cihak, MD is president of the Association of American Physicians and Surgeons (AAPS). Conrad Meier contributed to this article.