Drug Benefit won't help care until over medication Declines

James S. Gordon, Washington Post Reporter

Detroit News, Sunday, August 17, 2003

Much of the Medicare discussion has focused on the elderly need for more and better drugs, the problem of under medication and the danger of noncompliance (the failure to take a drug that has been prescribed). Those are certainly serious issues, and subsidizing truly necessary prescription drugs will partly address them.

This may be less problematic, however, than "overmedication" or the "inappropriate" use of "appropriate" drugs.

In 1998, an important article in the Journal of the American Medical Association indicated that "appropriately" prescribed drugs may kill as many as 100,000 Americans each year. People over 65 (the Medicare-eligible) are far more frq3untly prescribed medications than those under 65-- 5.5 prescription per year for those 55 to 64 years old vs. 8 per year for people 65 to 74, with the umber climbing to 11 prescriptions per year for those over 75.

Those of us who practice medicine are all to familiar with elderly patients dumping shopping bags full of drugs onto our desks -- drugs that have been prescribed over the years by two, three or a half-dozen physicians who have never communicated with each other. The drugs frequently work at cross-purposes and are sometimes out of date or no longer necessary.

In one study published a dozen years ago in the Archives of Internal Medicine, some 11 percent of emergency room admissions involved elderly patients were deemed to be the result of a failure to take prescribed medications. But an even greater number -- 16 percent -- were for adverse reactions or harmful interactions between drugs.

Several studies published in major medical journals have shown that between 15 and 25 percent of elder, non-hospitalized patients are prescribed drugs that are regarded as inappropriate for them. This means that solid scientific evidence has shown these drugs are likely to cause significant problems in elderly people, whose organs are more vulnerable than those of their  younger counterparts.

According to the federal Agency for Healthcare Research and Quality, as many as 1 million older Americans a years are prescribed drugs that should "always be avoided" by the elderly, including some widely used oral diabetes drugs, tranquilizers and anti-inflammatory medicines.

Then there's the effect caused by the rise in drug advertising. In several studies, physicians acknowledged they gave in and prescribed unnecessary drugs to persistent patients who had been impressed by ads they saw.

Neither the Senate nor the House bill will in any way reduce this epidemic of inappropriate prescribing and over-prescription. Indeed, if current practices persist, government subsides may actually increase inappropriate prescribing.

Though conscientious health professionals do their best to prescribe thoughtfully, they come under pressure from the economic exigencies and time constraints of the Medicare system. The end result is that many Medicare patients, whose problems are often more complex, are actually seen for shorter periods of time than other patients.,

A prescription drug benefit will benefit elderly Americans only if we are clear that drugs are an element in, not the focus of, their health care, and only if this subsidy is embedded in a more comprehensive approach to Medicare. Tow simple but far-reaching changes would go a long way toward accomplishing these goals.

First, we need to redesign the Medicare reimbursement scheme so physicians are appropriately compensated for spending more time with patients. such time is necessary to talk with the elderly about the texture and quality of their lives, as well as about the quantity, appropriateness, side effects and possible interactions of their medications.

Second, we need to stop focusing so narrowly on pharmaceutical treatment -- what doctors do for patients. By doing so, we have neglected, and may even be undermining, the greatest resource the elderly have: their ability to help themselves.

Elderly people often say they feel isolated and powerless, and these feelings contribute significantly to their depression and disorientation that bedevil them. Studies have shown that programs and interventions that address these feelings-- and encourage people to take an active par tin their care-- will improve their health and may6 even extend their lives.

We were taught in medial school that symptoms are produced by disease processes: It makes no sense to prescribe painkillers while a burst appendix is poisoning the belly. We need to encourage health professionals to address the causes of illness and teach the elderly to help themselves. If we do not mandate ands support this approach, more money for drugs may simple be a prescription for less good care.