The US health care system is broken and needs to be fixed. Contributing to this problem is a broken drug-use system. Prescription-drug prices, perhaps, are the most visual evidence of the broken drug-use system. The reason why the cost of prescription drugs is an issue, however, is not as clear to everyone. The rhetoric about the issue is loud, perhaps not always factual, and clearly conflicting.
If we were content to treat hypertension today with hydrochlorothiazide and reserpine, no one would be complaining about the cost of drugs to treat chronic diseases. If the breakthrough drug therapy to ameliorate the symptoms of HIV/AIDS and prolong the life of the sufferers of this disease were not available, would we be complaining as much about drug costs? I use these as just 2 examples of the value of modern drug therapy. We can treat problems untreatable a decade ago.
The cost of drug therapy, however, seems to be a problem for all payers, so we hear frequent complaints. Although the drug portion of the health care dollar is not the largest, it has been getting more than its share of attention. I might suggest that we should accept the increased use of drugs as evidence of the success of drug therapy. Without the successful use of drugs?keeping people out of hospitals, more physically active, and free of many symptoms?our health care crisis might be worse. My concern is that, as we try to deal with the cost problems today, some of our solutions may result in my grandchildren not having access to new drugs when they get to be my age. Yes, we need some changes, but let's be careful.
Some people want to find a villain, blame the villain for the problem, and make the villain pay for the high cost of drugs by some form of penalty. The blame has been placed on the greed of market manipulation such as direct-to-consumer advertising; inappropriate education of health professionals; multitier pricing; three-tier formulary systems; etc. Often the players involved want to point the finger of blame at the other parties, assuming that what they do is right so changes and savings will have to come from others, but not from them. This attitude often results in turf battles and protectionist action.
Perhaps all segments of the drug-use system feel under pressure?that is certainly true of pharmacists. Community pharmacists often feel the patients' frustration because the money is exchanged in their stores. They have to deal with the confusing administrative regulations of the different payers and collect the appropriate copay from the patient. Although in most cases they are only passing on the costs set by others, they are often blamed for the cost of prescription drugs.
What is the solution? Pharmacists do not agree on a solution, either, as was evident with the recent Medicare Drug Benefit proposal. When the conference committee report was released and voting was about to commence, 1 national pharmacy organization told pharmacists to oppose the legislation; 1 organization took no position, leaving it up to their members to decide what position to take; and 2 organizations encouraged their members to support the legislation, thinking that it at least provided a starting point to begin to improve the current situation.
Can a marketplace-driven system work if given a chance, or must we implement a single-payer system? Whatever the answer, some truths need to be acknowledged.
1. When drugs work, they are a bargain. This fact suggests that we must focus on achieving appropriate drug therapy with effective assessment or monitoring. Pharmacists see the patients more frequently than any other health professional. They should be recognized and reimbursed for drug-therapy management.
2. The Asheville Project (J Am Pharm Assoc [Wash], March/April 2003) has become a national model to demonstrate the value of drug-therapy management of chronic disease by pharmacists. The cost of drug therapy went up, but the cost of care went down and continues to be less each year. Clinical parameters continue to be improved, patient well-being has improved, and patient satisfaction with care also has improved. The pharmacist serving as the patients? coach and counselor at monthly or bimonthly visits keeps the patients accountable for the agreed goals, provides encouragement and information as needed, and then provides regular feedback or referral to the patient?s physician. In this way, care can be coordinated and early interventions can occur.
3. No single professional knows all there is to know?or has the time to do everything that needs to be done?so we must work together to solve this problem, and we must willingly share appropriate information among us. The days of turf battles and ?he did, she did? must stop, or everyone will lose. No component of the drug-use system is without some fault; so let?s acknowledge that the system is broken and then work together to fix it.
4. ?Just because we can treat it doesn?t mean we must treat it? should apply to drug therapy too. There are finite resources to cover health care costs, so tough choices will have to be made. We will need to do a better job of answering this question: ?If we can?t afford unlimited access to all health care for everyone, are there some components of health care that should be considered a right for everyone, while some other elements are available to those who can afford them??
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