Nothing in life is free, the old saying goes. But maybe some things should be, according to a new University of Michigan Health System study.
Specifically, researchers find, a group of medicines called ACE inhibitors should be available at no cost to the 8 million Americans over age 65 who have diabetes. These drugs are so beneficial for these patients that even giving them away ultimately would save the Medicare system and society large amounts of money by preventing heart attacks, strokes and kidney failure, the study shows.
And of course, the drugs would save lives, and make life better for patients. The findings, based on a sophisticated computer analysis, appear in the July 19 Annals of Internal Medicine.
Right now, cost or lack of awareness keeps many older diabetes patients from taking ACE inhibitors, which reduce blood pressure and cut the risk of diabetes-related problems in the cardiovascular system and kidneys. In fact, fewer than half of patients who should take them actually do take them.
The new study is especially timely because for the first time ever, Medicare soon will begin covering part of the cost of prescription drugs for people over age 65. That should increase the use of ACE inhibitors by seniors with diabetes, as their out-of-pocket cost for the drug declines.
But under the new Medicare plan, seniors will still pay for part of their drug costs in the form of premiums, deductibles and co-pays -- and research has shown that even small out-of-pocket costs keep many people from taking drugs that can help them.
Says lead author Allison Rosen, M.D., M.P.H., Sc.D., "Patients' out-of-pocket costs such as co-pays are a blunt instrument designed to keep patients from over-using medications, but they create barriers to the use of essential and non-essential medications alike. Our analysis shows that removing all patient costs for diabetes patients taking ACE inhibitors could save Medicare both lives and money."
The same may be true for other drugs that have a major preventive benefit, she says; future studies will assess what would happen if patients could get them free or at a reduced cost.
That principle, called the "benefit-based co-pay," is gaining more attention in the insurance field as a more sophisticated way to structure prescription drug benefits. But Medicare's new drug plan currently doesn't provide for the approach.
The benefit-based co-pay was first proposed in 2001 by Mark Fendrick, M.D., a co-author on the new paper and professor of internal medicine at the U-M Medical School. Rosen, an assistant professor of internal medicine at U-M who performed the newly published research in part while at Harvard University, explores drug costs and benefits though computer models. She worked with Sandeep Vijan, M.D., M.S., of U-M and the VA Ann Arbor Healthcare Center, on the new paper.
The new finding is based on a model that takes into account the substantial known health benefits of ACE inhibitors, the rates and costs of diabetes-related complications among people over the age of 65, the current and projected costs and use of ACE inhibitors by older people with diabetes, and the impact of even modest cash payments on patients' prescription-filling behavior.
ACE inhibitors have been shown to slow the damage to the kidneys that is often experienced by people with diabetes, and prevent them from entering end-stage renal failure (ESRD) in which the kidneys essentially shut down and patients need dialysis. ACE inhibitors have also been shown to cut the extra-high risk of heart attacks and strokes faced by people with diabetes; around 60 percent of people with diabetes die of a cardiovascular problem.
"There are many drugs that are effective, but few that are this dramatically effective," says Vijan. "Our analyses suggest that co-payments for ACE inhibitors may actually cost Medicare and other insurers more money by providing barriers to use of these drugs. It is sound policy, both from a patient perspective and from a fiscal perspective, to analyze drug co-payments on a case-by-case basis."
"All in all, ACE inhibitors are widely recommended as important medications for almost anyone with diabetes to take," says Rosen. "But cost has been shown to get in the way. And so, the Medicare program -- and all American taxpayers -- are paying instead for the hospital bills of people who had heart attacks and strokes that might have been prevented if they'd been taking ACE inhibitors."
The researchers assumed that if Medicare made ACE inhibitors available for free to any enrollee with diabetes, the use of the drugs would increase from 40 percent of patients to 60 percent of patients. Based on research into the effect of co-pays on patient behavior, they projected that the new Medicare drug plan, which will cover about one-third of the cost of the drug, will increase usage from 40 percent to about 47 percent.
The researchers based their model on the drug called lisinopril, a generic ACE inhibitor sold as Zestril or Prinivil that costs around $200 to $300 per year, though bulk purchasers such as the Department of Defense health care system pay much less. The new Medicare drug plan will not negotiate prices on a national level because of a clause in the law that establishes it.