By Stephen C. Schimpff, MD
Henry called and told me he was on 23 (!) prescription medications. Not only was he not feeling well but he really could not afford them all. What should he do?
Today there are more and more individuals with chronic illnesses. This is due to a combination of an aging population (“old parts wear out”) and lifestyles (overeating, inadequate exercise, chronic stress and smoking) that predispose to diseases like diabetes, heart failure and cancer. These patients need careful attention from their primary care physician (PCP) to coordinate what is often a multi-disciplinary team of specialists. Someone has to be in charge – to orchestrate the care. Absent this orchestrator it is all too often that the patient gets sent to too many specialists, gets too many tests, too many X-rays and, as in this story, too many drugs.
I have known Henry for many years, but we live 400 miles apart so we rarely see each other. (I have changed his name and some details to protect his medical privacy.) He is 69, recently lost his wife of over 50 years and lives alone although there is family nearby. He is retired with a small pension supplemented by Social Security. He has Medicare, a Medigap policy and a Part D drug insurance policy. But with 23 medications, he had enormous co-pays and soon met the notorious “donut hole,” so that he had to pay the full amounts.
He was recently hospitalized in the intensive care unit with a serious urinary tract infection that had spread to his kidneys (pyelonephritis) and to his bloodstream (septicemia) for which he was given potent antibiotics intravenously. After a difficult few days, he recovered, a tribute to the skill and care of his doctors and nurses.
A week after discharge Henry called me and asked for some advice. He was taking twenty-three different prescription drugs, some once, some twice, and some three times per day along with one via a monthly shot. He was not certain why many of them had been prescribed and asked if I thought he needed them all.
I offered to review the list and suggest some questions he could ask his physician. In looking over the list, I saw there were three for high blood pressure, two for heart failure (he said he had no idea he had heart failure), two for diabetes, one for depression, one to reduce his cholesterol, one to shrink his prostate (it was felt that an enlarged prostate had been a predisposition to his urinary tract infection), and a monthly shot of testosterone, among others.
Starting with the blood pressure meds, I asked him if he knew why he was getting three drugs, each in high dosage. He responded that every time he saw one of his physicians they would take his blood pressure, find it high and increase the dose or add a new drug. I asked if any one of these four doctors was in overall charge of his care and if the four communicated with each other? The answer to both was “No.” He really did not have a primary care physician; he just went to whoever he thought might be most appropriate for the problem of the day. Naturally, each checked his blood pressure when he went for a visit.
I asked if he ever got his blood pressure checked at the drug store or supermarket. He told me that he did and it was always normal. I told him that he might have “white-coat hypertension,” meaning it was high only in the doctor’s office. Perhaps if Henry took his regular readings to the doctor, the physician would take him off one or more of these drugs. But he would have to have just one doctor responsible for his blood pressure.
I wondered why he was getting a testosterone shot each month. As it turned out, it was because he had developed erectile dysfunction a while back, and one doctor thought the testosterone might help. Perhaps, but two of the three high blood pressure drugs have a known side effect of impotency. So this was likely a side effect which was being treated by another drug instead of dealing with the cause of the problem. Besides, the testosterone might well have caused his prostate to enlarge, leading to the urinary tract infection that nearly cost him his life. Maybe if he was off the testosterone, he would no longer need the other drug to shrink his prostate.
There were issues with some of the other drugs he was taking, but you get the picture. In brief, Henry was getting unnecessary drugs for hypertension They caused a side effect, for which he got another drug, which in turn caused its own side effects. And now he was on an additional drug to treat what problem the second one might have created. Most importantly, no one person was in charge; no one was listening carefully and coordinating his care.
Henry’s story represents much of what is not working in the delivery of medical care today. His complex, chronic illnesses—heart failure, diabetes and depression (and maybe high blood pressure)—all require attention and care coordination, preferably by a single PCP who knows his home and social setting as well as his direct medical issues. Finally, all these drugs were expensive, both for him and for his Medicare Part D insurance plan.
Heart failure and diabetes together consume more than half of our health-care dollars, yet no one adequately monitored Henry’s care; rather he was getting one drug after another without attention to what else was happening. This lack of care coordination is a prime example of why health-care costs are so high, yet its quality is still so low.
My first suggestion was that Henry needed a primary care physician, one to call his own. He learned that a young doctor he had met at a nearby hospital would be setting up private practice near his town, so Henry became one of his first patients. Henry still has three very serious chronic conditions. But with a single physician serving as an orchestrator rather than simply as an intervener, one who actually pays attention to Henry’s personal circumstances, Henry has better quality medical care and a much higher quality of life.
Like Henry, you need a single primary care physician to orchestrate your care, especially as you get older and inevitably develop some chronic conditions. You will have better health, better care, be more satisfied, and spend much less money. Find a PCP who will spend the time you need for good preventive care and for careful care coordination. Be clear about your needs and look elsewhere if you are not satisfied. It is your health and your money!
Henry called me again with a follow-up about three months later. He was now taking only seven medicines, felt better, and he is spending less money—both his money and that from Medicare, Medigap, and Medicare Part D. In short, his well-coordinated care is a win-win for all concerned.
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Stephen C Schimpff, MD is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and is chair of the advisory committee for Sanovas, Inc. and senior advisor to Sage Growth Partners. He is the author of The Future of Medicine – Megatrends in Healthcare and The Future of Health Care Delivery- Why It Must Change and How It Will Affect You, from which this post is partially adapted. Updates are available at http://medicalmegatrends.blogspot.com