On health care's cliff: More meds isn't necessarily good medicine

There’s a pill for every ill.

And a bill that’s going to be past due before many people even know it’s coming.

Like their beltlines, Americans’ appetite for medication keeps growing.

“When I started training, it was a big deal if somebody was on five or six medications,” says Dr. Joseph Abate, medical director at Heritage Health in Coeur d’Alene and a former cardiologist for almost three decades. “That usually meant they had some serious illness. If you had heart disease, that was the time we were adding three or four medications to try to treat that heart disease.”

And now?

“Now it’s not uncommon to be on 10, 12, 15 medications,” he says. “That has happened over time. Every time a study comes out that shows even a small benefit — maybe 10 to 15 percent benefit over the five drugs somebody’s already on — that’s considered a reason to add that additional drug. There seems to be no end to adding the seventh and the eighth and the 10th and the 12th drug because evidence-based medicine showed that there was some benefit.”

But in the ultimate cost-benefit analysis, Abate believes an important element is generally missing.

“There’s no talk about diminishing returns,” he says. “After a while, I think your life becomes less fulfilling. It becomes more about, ‘Did I take all my medications today?’”

Through diligent patient interaction and a program he calls Kroc Rx, Abate is doing his best to rebalance the prescription proliferation. As a physician, he knows some medications are absolutely essential — godsends, really — for patients to enjoy a reasonably high quality of life. But he pushes hard to tip the scales back toward something resembling sanity, no easy mission considering he’s opposed by a populace generally predisposed to quick and painless remedies, and by an industry that often puts profit before any humanistic consideration. Abate and clinical pharmacist Denis Yost of Coeur d’Alene would like to ease the yoke binding drug companies to drugged citizens.

“We’re one of only two countries that allow direct-to-consumer [drug] advertising,” Abate says, adding that New Zealand is the other. “So every day, when you’re hit over and over again with commercials that tell you your life could be better. . . it’s what I call ‘symptom as disease.’

“You’re bald? We’ve got a pill for that.

“If you’re impotent, we have a pill for that.

“If you couldn’t sleep last night, we have a pill for that. If you were anxious, we have a pill for that.”

TOUGH QUESTIONS

How did we get so immersed in the prescription drug culture? he’s asked. And which came first in line for the blame — the doctor who should know when to say enough meds are enough, or the patient who demands more and more?

“This all came about innocently enough,” Abate says. “If you’re a doctor, you want to do whatever you think is best for the patient. If a study comes out that tells you there is yet something else you can do for a patient to make their life a little bit better, you jump on that. And if you’re the patient, and you think there’s anything that might make your life a little bit better, you’re going to jump on that. It’s only after you get to the point where you see a list of 20 medications and you say, ‘Wait. We have to make some choices here.’

“Is it really worth $600 a month to get a 10 percent improvement in something, especially if you can say that exercise has been shown to give you the exact same improvement?”

Big drug companies would emphatically say “yes,” Yost suggests.

“Drug companies used to be ethical,” he says. “Somebody pushed the market and everybody started doing it. Now it’s gone to where they charge whatever they want to charge — because they can.”

“It’s profit,” Abate agrees. “It’s being accountable to your shareholders. If what you want is to make a profit, there’s lots of ways to do that, so they started doing things that weren’t necessarily in the patient’s best interest but would maximize profit. They began buying generic companies or paying generic companies not to produce their generic medication. So it was nothing for a company to pay $50 million to buy a generic company and have them shutter their doors for a year.”

RATIONING HEALTH CARE

If that sounds cold, even ruthless, Abate and Yost believe that’s because it really is.

As an example, Yost talks about a drug to treat hepatitis that came to market after a large pharmaceutical company bought a program from a small biotech company.

“They come out and just price it at $1,000 a pill — not because it costs $1,000 a pill, but because they wanted to test the market and see if they could get it,” Yost says. “And they could. It’s a very good drug, but in India and Egypt it only costs $900 a year. Here it’s $98,000 a year.”

Abate calls the drug “wonderful,” but not the ethics behind its pricing and distribution. In fact, the physician cites this as an example of pharmaceutical companies wielding too much power in the quest for health care solutions.

“Hepatitis C causes a lot of problems, and to be able to cure that is a terrific thing,” he says. “But at $90,000 to $100,000, what you’ve done is you’ve rationed medical care. And all those people who were so afraid the government would ration medical care have now allowed industry to ration medical care.

“If you don’t have insurance and you have Hepatitis C, there’s no way you’re going to be treated and cured. So now instead of treating everybody so that we can cure all of that Hepatitis C that’s out there, we’re now having discussions about who gets treated and who does not. The pharmaceutical companies are now rationing health care.”

Yost believes a fair price for the drug would be about $10,000, which he estimates would still generate profit of 15 to 25 percent. Abate says the formula for establishing drug prices is at best artificial.

“They look at the total cost of how much, during a lifetime, someone with the complications of Hepatitis C would cost the system and say, ‘Well, we’ll price it a little less than that so it will look like a bargain.’”

MORE SICK EXAMPLES

Yost describes a company selling cortisone injections that buys a patent after discovering their product can be used for multiple diseases.

“It originally cost $6 a vial,” Yost says. “Now it’s $28,000 a vial. I was talking to a drug rep and I said, ‘You know, that’s criminal.’ He says, ‘Oh, these diseases are expensive to treat.’ Well, yeah, they’re expensive to treat — because they’ve raised the price so much.”

Sometimes the prices are surprising for other reasons. Abate shares his experience with an antibiotic called doxycycline.

“It was $4 a month and then suddenly, with no explanation, it went as high as $1,600 a month,” he says.

“Lots of people in our institution were prescribing it because it had been $4, it covered a lot of illnesses and it was a good medicine. A lot of our people were in the habit of saying, ‘Try this,’ and all of a sudden we had patients coming back saying, ‘I can’t afford that pill.’ It was $300. And they’ve done that to a number of pills. As long as they can get away with it — until people notice it and complain — then they take it back down. But in the meantime, they’ve made years of profits, sometimes with devastating financial impacts to families.”

Yost cited a report released just last week that showed nationwide, 600,000 families pay more for medication annually than the entire income of the average family in America, which is about $50,000 per year.

“On a per capita basis, that means that 300 or more families in Kootenai County pay more for drugs than what they earn in the entire year,” Yost says. “That's why you have to have insurance.”

Abate says while there’s a place for profit, huge profits are problematic in the ideal practice of medicine. Some doctors, he acknowledges, maintain strong profits by quickly seeing as many patients as possible, writing prescriptions and sending them on their way.

Others go further.

“If you’re interested in profit — if your main reason for being a medical provider is profit — then you look for the profitable sectors,” he says. “You start a low-T clinic. You want to make a lot of money? Do a low testosterone clinic. People are making billions doing that.

“Pain management pain mill: That’s another. Buy your MRI — the patient purchases the MRI — and you say, ‘Oh, that looks really painful. Here’s your prescription. Thanks, and that’ll be $300 cash and we’ll see you next month.’”

So what’s the prescription for fixing the mess of runaway drug costs and citizens’ reliance on painless solutions for their problems?

“Really, it comes back to the relationship between the patient and the provider,” Abate suggests. “I think you have to know philosophically, what does your patient want? If your patient doesn’t want to be on 15 medications, then you can work with them to simplify things. If you’re the patient and you’re constantly in front of an onslaught of TV advertising, you will not know any different. The only way to combat what the pharmaceutical companies would like to do for profit’s sake is to just not use the medication. It’s the only way. Just don’t prescribe it.

“In some situations that’s possible. In other situations it’s not possible. You can’t not treat diabetes; that would be unethical. You can’t not treat hypertension. But you can not treat insomnia, because nobody ever died from insomnia and the medicines don’t work very well anyway. They make people worse rather than better in the long run.”

Instead, Abate has other ideas for making people better in the long run — ideas that at this very moment, are working. Tomorrow, we’ll share his unique prescription for better health.