A recent article in the New York Times, http://nyti.ms/1ABmGIg, demonstrated that there has been some apparent benefit from Medicare Part D, which most people know as the Medicare Prescription Drug Benefit. In fact, it should be known as the Pharmaceutical Industry Windfall Profit Program. Many of my patients told me at the time that just before the new benefit went into effect, the cost of many of their medications went up 30-40%. This included generic medications! While the "benefit" increased the amount of coverage that individual patients had, what it in fact did was subsidize a huge windfall profit for the pharmaceutical industry. The article does note that the group of people that are still struggling with medication issues are those people on multiple medications. These are the people that we need to be focusing on the most in the Medicare system, as they are ultimately the ones who utlize the greatest amount of resources.
At the time that Medicare Part D came into being, I posed the following question, "shouldn't we be more concerned about why so many seniors are on so many medications?" Instead, we just focused on helping seniors pay for medications, many of which they did not need. I have written many articles about how many health care providers are not adequately trained in the field of geriatrics. This leads to the prescribing of many unnecessary and often harmful medications. During my thirty year career as a geriatrician, I have stopped more medications than I have started. The most egregious case was one of an older woman who came into my office, in a wheelchair, on 50 medications! Over the course of one month, we reduced the number of her medications down to three and she felt much better, and could walk on her own.
Why are Medicare beneficiaries on so many medications? There are a lot of reasons, none of which include any significant evidence for many of the medications that physician prescribe. Physicians who care for Medicare beneficiaries are incentivized to spend as little time as necessary with a patient. Writing a prescription takes much less time than explaining why they don't need one. The marketing of medications rarely acknowledges that the medication has not been adequately studied in older people, much less than in older people with any degree of frailty. The addition of a Prescription Drug Benefit has only served to make the prescribing of medications to Medicare beneficiaries more palatable for seniors. It is an ironic twist that medication non-compliance due to lack of ability to pay for a medication may actually help some people who are needlessly on too many medications!
What do we do to improve this situation? The Medicare D program has created an entire new health care industry, which basically adds an additional silo of care to an already overburdened system. I will endeavor to come up with two types of solutions, one for those who believe in government run health care and one for those who don't. Take your pick, I believe that both are actually feasible!
Since the government is paying for people's medications, one could argue that they should singularly control that process. While I am not generally a fan of more government, in this case I believe that it's the devil you know that wins out. The government should be responsible for the Medicare Part D program and should have the ability to negotiate with the pharmaceutical industry on pricing. Why should the government as a payor be forced to accept whatever the industry charges for medications? Where are the free market principles in that?
There is another interesting approach that could be taken that would take the government out of the picture. Give every Medicare beneficiary a voucher payable to their Medicare D provider. All medications that they ever need would be covered by this voucher. The amount of the voucher would be the average amount presently spent on medications by a Medicare beneficiary, minus 5-10%, as we need to be lowering these costs. This would put the pressure on the Medicare D providers to negotiate for better pricing, as well as to develop more effective guidelines for the prescribing of medications. And, it would occur in the free market.
We all intuitively know that older people are given too many medications. Let's stop supporting this and work towards changing the system and improving the health of older adults!