Older Patients, Wiser Care
A Way to Lower Drug Costs: Make Sure They're All Still Necessary
Last updated:June 14, 2010
Dear Dr. Kernisan: My 80-year-old mom who has dementia is having a hard time affording all the meds she takes. With her coverage, she must pay the total cost from May to December, which she doesn't have. Where can she find help? Thanks, Craig
Schedule a visit with her doctor. Ask for a medication review, and be sure to specify that you want to review the benefits of each drug, and try to reduce the monthly drug costs if possible.
Although it's sometimes possible to cut costs by getting the same drugs less expensively, I always recommend that people concerned about drug costs start by asking a doctor to help try to trim the list down.
After all, in today's busy practice environments, it's easy for an older adult's medication list to end up being longer than it may absolutely need to be. In the geriatrics practice I'm part of, we find that a careful medication review often allows us to identify several prescriptions that can probably be stopped safely. This can make a big difference to a person's monthly drug bill.
Here's the process I use with my elderly patients:
First, we classify the medications taken into one of three categories:
1. Medications for symptoms. These include drugs to treat daily problems such as pain, incontinence, allergies, heartburn, or even depression.
2. Medications for risk reduction. These drugs usually don't help a person feel better on a day-to-day basis, but instead are meant to reduce the chance of a future serious event, such as a stroke, heart attack, or hip fracture. Although people commonly think of these drugs as "prevention," we can never know exactly how well they're helping an individual patient: Many people who take a drug for prevention will still experience the serious event, and many who don't take the drug won't have the event.
3. Medications that do both. Some medications both help a person feel better and may keep a disease from progressing as quickly. These include certain drugs used for congestive heart failure or inhalers used for chronic obstructive pulmonary disease (COPD).
Next I consider how well each drug is working for the particular patient. If cost is an issue, this is also the time to think about whether cheaper alternatives exists.
For the symptom drugs, we review how effective each seems to be at maintaining the patient's quality of life. It's not uncommon to discover that even after a drug has been ramped up to the right dosage, a problem (such as mild depression or incontinence) doesn't seem to be much better. After all, not all drugs work for everyone. If that seems to be the case, we might decide to focus instead on a non-drug approach (such as counseling for depression or timed toileting for incontinence). Or, depending on the situation, we may decide to switch to a different drug.
For each prevention drug, we try to provide a ballpark estimate of just how likely it is that the drug will prevent the problem it's supposed to be targeting. For instance, many people take a statin, or cholesterol medication, to reduce the chance of having a heart attack. However, the likely benefit may be smaller than many people realize: Researchers have estimated that in those who already have coronary artery disease, at least 50 people need to be treated with a statin for four years in order to prevent one extra death. For the other 49 people, the statin doesn't end up making a difference. (Business Week ran an interesting article a few years ago with a good explanation of this "number needed to treat".)
Unfortunately you can't know ahead of time whether you'll be the one out of 50 who benefits. But you can think about whether the ballpark chance of benefit is worth the money that the drug will definitely cost you every month. This is the point where many of my patients and their families opt to cut back on some of the prevention drugs. This is especially true in cases of moderate or advanced dementia, or if the person's overall health is declining due to other medical problems.
One example: An extensive, federally-funded review recently concluded that the drugs we use to try to slow dementia aren't very effective. For those families worried about their out-of-pocket drug costs, I often suggest a trial off these drugs. Usually the patient doesn't seem to be any worse, and the savings can be considerable. (And you can always ask for the drugs to be re-started, on the off-chance you find your loved one seems to have declined without them.)
Some people, of course, prefer to continue drugs for prevention. In the end, it comes down to personal preferences and choices. But given how many prescriptions an older person may accumulate over time, and from multiple doctors, it's a worthwhile process.
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