As many readers know, I’m currently working on a new edition of Clinical Management of Heart Failure. This is the third edition in the series, and the first update in about 10 years. I’ve just finished a completely new chapter devoted to the management of heart failure patients with major co-morbid conditions. I haven’t seen anything quite like it, and I thought it would add something of real value to the book.
The conditions that I chose to focus on include Type 2 diabetes (T2DM), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), and cancer. In the course of doing my homework (Yes, Virginia, there is ALWAYS homework!), I’ve documented that the “average” heart failure patient has up to a half-dozen other important medical problems. About half of the heart failure patients have T2DM; one in every four or five has COPD, and about 4 in 10 have Stage III or higher CKD.
In addition, dramatic improvements in cancer management of the past two decades have given rise to a whole new specialty called “cardio-oncology.” Cardio-oncologists are cardiologists with special expertise in managing the various novel forms of heart injury associated with both chemotherapy and radiation treatments for cancer.
Now, what does this have to do with drug costs? Let me suggest that you have a look at an interesting article in the Wall Street Journal that involves a discussion between senior individuals in pharma, insurance, and AARP. Read it carefully! The interesting part is what isn’t there. These leaders all actively press their own agendas, and represent their own perceived constituencies. Not one of them raises the concern that disease is not evenly distributed in the population. The concern about the rising costs of prescription drugs for medically managed chronic applies to fewer than 20% of the population. This subset tends to be older, to have multiple co-morbidities, and to take multiple prescription drugs. (The prevalence of obesity, substance abuse, firearms, and traffic accidents means that a substantial subset of the US population is not “healthy,” but that (approximately) third of the population does not qualify as having a medically managed chronic disease.)
The currently favored buzzwords for dealing with the drug cost “problem” are “transparancy” and “empowerment.” Let me ask you a serious question. Do you think that your 83 year old Aunt Margaret, who has high blood pressure, diabetes, a chronic cough from 50 years of a pack of Chesterfields a day, and is getting a bit forgetful, is going to carefully analyze her drug costs and discuss the issues with her doctor and her pharmacist? I’m skeptical.
As the WSJ piece makes clear, drug costs for such patients are already vigorously negotiated. “Doing something” about the cost of chronic illness is going to require either limiting care, which most of us find unacceptable, or improving the efficiency of care. Can we do that with improved access to nurse practitioners who can prescribe generic fixed-dose combinations? Sure. But only if we are willing to accept the concepts that the pharmaceutical costs of managing older patients with multiple chronic diseases are the costs of success, not failure. These patients are living longer, with more complicated problems, than ever before. Their drug costs are relatively small.
We can’t let the headlines about an occasional rogue company raising the cost of drugs for relatively rare conditions (e.g., Daraprim for toxoplasmosis) make us lose sight of the real issue here. The large, ethical, research-based pharmaceutical companies have contributed enormously to improvements in quality of life; they have to be able to continue to fund drug research and to generate reasonable profits for their shareholders. Yes, there are some practices in the pharmaceutical industry, particularly direct-to-consumer advertising of specific drugs, that should be curtailed. But let’s not confuse poor judgement with malice, and let’s try to stick to the facts when we think through our health care options.