Wrestling The Octopus
William D. Novelli
Executive Director and CEO, AARP
National Center for Patient Information and Education and The
Peter Lamy Center on Drug Therapy and Aging Conference
High Tech-High Touch: Advocating Quality Medicine Use Among Older
Adults
Bethesda, MD
October 17, 2002
Improving the use of medications among older adults is like wrestling an octopus: Two arms are hugging you, two arms are trying to strangle you, and God knows what the other four arms are doing. Every time you think you're making headway solving one aspect of the problem, another one reaches out and grabs you and pulls you back.
The octopus that I have in mind - and that seems at times to have us by the arms, legs, and throat - and the pocketbook - is the American health-care system. One reason that it seems to be an octopus rather than a Clydesdale, steadily pulling the wagon along, is that the system is not really a system at all, as many of you know so well.
The focus of this conference is improving medicine use among older adults. The main point I want to make today is that to be successful in doing that, we have to wrestle with many other issues as well. Improving medicine use among older adults is not an isolated issue. It's part of a systemic problem. And, we can't solve the problem by attacking only one aspect of it. We need to employ a wide range of strategies to wrestle this octopus.
Let's look at what we're up against. On one hand, we have in America the world's preeminent medical research. We have health delivery mechanisms that are splendid - for some people, some of the time. We have some the finest hospitals and physicians anywhere in the world. We have remarkable pharmaceutical research and products.
It is amazing to consider the vast array of drugs available to us to reduce pain, prevent and fight infections, treat depression, arthritis, many cancers, and all kinds of disorders and disease. Not that long ago, the world was without aspirin, antibiotics, and flu shots.
Imagine what our lives would be like without some of the new drugs that enable us to live longer and better lives even in the face of chronic conditions. I am referring to beta blockers, statins, anti-inflammatories, anti-depressants, chemotherapy drugs, and so on. Without the basic research and the pharmaceutical developments that follow, we would have none of these. Our lives would be more difficult and, in many cases, shorter. We are thankful for our publicly funded medical research and the pharmaceutical industry for bringing us such wonder drugs.
On the other hand, we also have about 40-million of our fellow citizens without health insurance. Health-care costs are going up and quality of care seems to be going down. We have areas in the country where the nearest doctor is 100 miles or more away. Many of the remarkable medications we have developed-and that keep us living longer and better-cost too much:
- Prices of prescription drugs have been rising at nearly three times the rate of general inflation. Spending for drugs tripled in the last decade and is expected to more than triple again in this decade.
- Nearly one American woman in five between 50 and 64 did not fill a prescription because it was too expensive for her.
- People are skipping doses and splitting pills to save money.
As we try to grapple with this part of the octopus-affordability of prescription drugs-we find another tentacle threatening us, then another and another…the lack of health insurance, the need for more geriatric training in medical schools, the problems with long-term care. This octopus has more than eight arms.
The impact of rising drug costs is being felt throughout the nation: by consumers, employers, employees, insurance companies, and state governments. But rising costs especially hit older people and those caring for them. Older Americans rely on prescription drugs the most, and they are just about the only ones paying full price for their medications, because Medicare does not cover prescription drugs. For millions of older Americans and persons with disabilities, rising drug costs constitute an intolerable health-care and financial burden that must be addressed now. As I said, we have many problems, but we will not defeat the octopus until Medicare covers prescription drugs.
Unfortunately, Congress is not helping. The House of Representatives passed a modest prescription-drug bill in Medicare. The Senate was unable to come together to pass any Medicare prescription-drug coverage, even though 99 of the 100 Senators were on record as supporting a prescription-drug benefit in Medicare. The Senate had reached some agreement around a $400 billion Medicare Rx package over ten years. Yet, they could not agree on how to deliver the benefit, how a federal fallback delivery system would work if a private delivery system failed, or whether to include an assets test for the benefit.
Underlying these differences is political partisanship. Many Senators seem to believe that a prescription-drug benefit in Medicare is more valuable as a campaign issue than as policy and legislation, leaving millions of people in the lurch. The result is that politicians have an issue to argue about and spin during the election campaigns. And older Americans will try to save money by taking less than the prescribed doses of their medications, or by not taking them at all.
Instead, the Congress turned its attention to financing another round of provider givebacks-more than $40 billion worth-of which less than 10 percent would directly benefit Medicare beneficiaries. This will result in a rise in people's Medicare Part B premiums-$6 billion in the first five years alone.
Keep in mind the context in which this is happening:
- These added costs to beneficiaries come on top of double-digit hikes in prescription-drug costs for older Americans, many of whom have little or no options for drug coverage. High drug costs are not only breaking the budgets of many older Americans; they are also hurting businesses and draining state budgets, with 40 states currently facing Medicaid shortfalls driven by unsustainable drug costs.
- More and more employers are reducing or eliminating retiree health-care coverage.
- Nine more Medicare+Choice plans are pulling out of Medicare completely-the fifth year in a row private companies have left the Medicare market.
- And, just recently, Together Rx, a good industry discount card that offered savings on 150 brand-name medications, involving eight manufacturers, made changes as some companies withdrew from the program and others raised their discounted rates. This card was to provide pharmaceutical-industry help for low-income assistance, yet it serves fewer than 150,000 of Medicare's 39 million beneficiaries.
Well, it sounds like the octopus is winning, doesn't it? One point is clear: this is not the way to improve medicine use among older adults.
But, let's not give up the fight. Octopus wrestling takes courage, perseverance and all the resources we can muster. At AARP, we've committed to bring down the cost, increase the availability and improve the use of medication among older Americans. The payoff-in increased independence, quality of life and financial savings-is huge.
Last week, I was in Oregon where we are working with Governor John Kitzhaber and others on Oregon's Practictioner-Managed Prescription Drug Plan. This is a first-rate plan because it does four things that help fight the octopus:
- It tackles a genuine, and serious, problem, in the public arena, which in turn requires a solution from the public sector.
- It is based on evidence and science.
- It is based on marketplace solutions: research the information to know which drugs are comparable for most people, and have the manufacturers of those drugs compete for state business on the basis of efficacy and price.
- Finally, it has the flexibility of physician-directed exceptions for those cases where a drug is not comparable to others for an individual.
The Oregon plan comes up with an evidence-based practictioner-managed preferred list of drugs that are safe and effective for most people. It provides unbiased scientific research about drugs that are therapeutically similar, but not generic equivalents. For example, it compares different brands of cholesterol drugs, none of which is yet generic. And, it helps to determine whether brand-name arthritis drugs such as Celebrex and Vioxx can be replaced by generic painkillers such as ibupofen. Ibuprofen is not generic Vioxx or Celebrex; they are in chemically different categories. But, the research suggests that they do the same thing for most people, and should compete against one another on the basis of price.
What we also like about this plan is that it has an exception policy so that physicians will not have their hands tied when they reach for their prescription pads. The patient will always be able to get the medicine the doctor believes is best for him or her, so the Oregon Prescription Drug Plan will reduce drug costs, but it will not reduce access to necessary drugs.
I'm proud to say that AARP is leading a consumer-awareness campaign in Oregon that is helping to disseminate the Plan's research in consumer-friendly ways. And, it's working. From August 21st through the end of September, over 18,000 people visited the website where Oregon's Prescription Drug Research information, in the form of a consumer guide, is available. To visit the website, go to www.aarp.org/or and click at " Be Drug Smart". It is extremely useful information and is the first step towards a comprehensive consumer guide for prescription drugs.
This approach also strikes an appropriate balance between "high tech" and "high touch." It is taking an old idea - a list of approved drugs - but establishing it according to the principles of evidence-based research into the safety and effectiveness of the drugs, rather than merely the cost or non-medical criteria. This is public policy at its best.
And, it reminds us that when public policy grows out of research - objective, measurable, reliable - we can usually have confidence that we are getting something of true value for our tax dollars and a genuine, known benefit.
Well-thought-out, and well-funded, policies can be transformational in our society. But public policy has limits. On the one hand, the well-being of American citizens is a public concern, which is reflected in many public programs, including Medicare and Medicaid, nutritional information from the FDA, outcomes research conducted by the Agency for Healthcare Research & Quality, and so on. On the other hand, the practice of medicine in America is largely a private matter. Thus, the meeting of public and private interests requires constant examination, and frequent balancing of policy and personal practices…and personal responsibility.
So we think that it is important for people to Check up on Their Prescriptions and understand how to use medications wisely. We are engaged in a public education program to do just that. Our research shows that, even though people 45+ are taking lots of prescription drugs-especially those 65 and older-they are not realizing the full benefits of these drugs because they're not taking them as directed. Moreover, many are not using generics despite their comparable efficacy and lower cost. On the basis of this research, here is our basic message that we tell our members and the public:
- If generics are available, then take them, as long as your physician agrees. Many older people do not understand what generic drugs actually are.
- If a drug is not necessary, there is no reason to take it. Over-utilization can be physically harmful; can compromise the effectiveness of other drugs, and wastes money. And don't go in for overkill. For example: take Tums or Maalox for heart-burn, and save the expensive Prilosec for reflux disease.
- Under-utilization is just as bad. Take the medication your doctor prescribes. For example, some higher cost drugs such as statins, for high cholesterol and anti-hypertensives have been shown to be under-utilized.
We can and do reach a lot of people, and we are going to continue with the educational campaign to help people use prescription-drugs wisely (show AARP Modern Maturity insert). Information and education are critical in wrestling the octopus. When people have information and understanding, they can take better care of themselves and, if all goes well, may need to rely less on medical interventions to lead healthy lives.
So, we believe that health promotion and disease prevention are critical. The ounce of prevention is worth a pound of cure. And it is relatively cheap-indeed, often free. Research shows that, aside from quitting smoking (show Segunda Juventud), physical activity is the most important thing that older adults can do to live independent lives as long as possible. This can include disease avoidance…and less medication as well. So, we have been promoting physical activity to our members in numerous ways.
Being a couch potato is not funny - or fun. We are telling our members to get off their… couches. If you've got a moving part, move it!
We have some excellent partners in our efforts to increase physical activity among older men and women. Working with the Robert Wood Johnson Foundation, we are piloting physical activity programs in Richmond, Virginia, and Madison, Wisconsin. Media, community organizations, volunteers, and other interventions in these two cities over the course of a year or more will provide the experience and knowledge we need to expand this initiative nationally in the future.
And last year, in partnership with USA Triathlon, we introduced our AARP Tri-Umph Classic Triathlon - swimming, biking, and running - on a modified scale. This year we're holding events in 15 cities. This is the first such multi-sport event for people over 50. And we don't just tell people to sink or swim… or fall on their faces or fall off their bikes. The program begins with an optional six-to-eight week training course.
In many ways, the AARP Tri-Umph Classic Triathlons are symbolic of the new reality of aging. More and more people are living longer and living better, not just here in the United States, but throughout the world.
- With every coming year, over 4 million men and women will join the ranks of 50+ America.
- This is changing the fundamental age distribution in America. In 1900, only 13 percent of the population was age 50 or over. In 2000, it was over 27 percent. And, by 2020, it will be over 35 percent.
People turning 50 today have half of their adult lives ahead of them. They are using that milestone to question what they want to do with the rest of their lives, instead of viewing it as a time of decline. For many it is a time to enjoy new-found freedoms, make new choices, and dream new dreams.
Improvements in medicine and health care are at the very core of this new era. Think of the progress over the last 50 years-Medicare; medical advances in pharmaceuticals, therapies and diagnostics; the founding of the National Institute on Aging; a growing awareness that health and fitness mean more than chronological age. All of this has led to better health for people over fifty and longer life expectancies. There is a lot to feel good about because we know more and more about aging, and aging itself is getting better for us all.
Yet, this progress brings us new challenges, so we must continue wrestling this octopus. Earlier this year, we released Beyond Fifty: A Report to the Nation on Trends in Health Security, which identified the primary factors that influence the health security of 50+ Americans:
- Increased reliance on prescription drugs and other new health technologies has brought about major changes in the delivery of health care and has driven health-care costs and coverage structures.
- Chronic diseases and conditions are common among people over age 50, especially in the oldest age segments. But the systems that serve the chronically ill remain oriented largely toward acute medical care. Increasingly, the health-care needs of this population involve a range of services across the spectrum of physician, inpatient, outpatient, and long-term care.
- Greater longevity-and the functional limitations that accompany old age-have highlighted the need to live more independently and increased awareness of the quality of life, especially during the last stages of life.
- There is increasing recognition among those who provide or pay for care that patients need choices about quality and value. Informed decision-making is an increasingly important-yet often missing-dimension in consumer thinking about health security. For those needing long-term care, especially, the challenge of navigating a fragmented, uncoordinated, patchwork of public and private programs is very, very difficult.
- High and rising health-care costs make care less accessible for many 50+ Americans. Average spending per person over age 50 has increased, fueled largely by the increase in chronic conditions and spending for prescription drugs. Out-of-pocket spending on prescription drugs and long-term care represent the greatest health-related financial risk for older Americans.
So, as you can see, the health-care octopus does not give up easily. It will take us all working together to tackle the challenges ahead and improve the use of medications among older adults. But the progress we have made is significant and we should be optimistic. Increased and improved longevity is one of the great success stories of the 20th century, and today we have the knowledge, innovation and technology to make it even better. Yes, the health-care octopus is plenty tough. But together we can wrestle this octopus to the ground.
