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I read with great interest David Nash’s editorial, entitled “It Takes a Village” (in the September 2010 issue of P&T) on the importance of managing hypertension and the public health consequences.
Last December I had dinner with some folks (all of us had recently turned 50 years old) from a large payer, and we started the discussion about the number of meds and which ones we were on. It was fascinating because this is a very health-conscious, health-literate group of people. All of us had published in peer-reviewed medical literature on one topic or another. All were on at least one chronic medication.
When my turn came, I proudly announced that I was taking only an antihypertensive agent. When the medical director asked which one, I responded, “Benicar.”
He couldn’t believe it and said in a loud voice, “Why in the heck are you on an ARB [angiotensin-receptor blocker]?”
At that point, I sheepishly asked, “What is an ARB?”
He explained and said that my primary doctor should have tried an ACE inhibitor first to determine whether I would be one of the lucky 85% to 90% to avoid the annoying “ACE cough.” It was much cheaper and available as a generic. This was turning out to be a very interesting holiday dinner indeed!
I returned home, called my primary physician’s office, mentioned that I knew all about the cough side effect and requested the switch to an ACE inhibitor. I explained that I was doing it to save money for me and the health care system. I switched and worked through the cough over the next several weeks. My copay over 90 days went from $30 to $10, which is nice but hardly a retirement fund. I am quite sure the savings on the health plan side was more substantial. By the way, my dinner guest was not my insurer. Around the same time I read in Managed Care that if everyone in the U.S. who was prescribed an ARB had to fail a trial of a generic ACE inhibitor, the country would save $3 billion! I was beginning to feel like a proud American just doing his part to save the health care system from financial ruin.
Now it is not quite a year later, and I recently read that the ALLHAT study showed that a simple diuretic (chlorthalidone) is cheaper and performs better in every cardio-vascular measurement than the ACE inhibitor (lisinopril) that I am currently taking. I pulled up JNC7 and read it, but no firm medication recommendations are made other than to treat hypertension.
I am left wondering how many people in this country can wade through the medical evidence on a health care topic that personally affects them and make sound cost and quality decisions? In my opinion, there need to be clear recommendations that can be disseminated to physicians and patients, enabling them to participate together in care decisions so that the patient has a firm commitment to medication adherence. It does take a village and the patient needs to be a critical part of that village!
I read with interest Dr. Nash’s editorial, “It Takes a Village.” After being in this business both as a practitioner for almost 20 years and in managed care for almost 15 years, it saddens me to see numbers like this. Despite all of the antihypertensives and all of the millions of pages written in these 38 years since I started medical school, compliance is still the key element in treating this dreaded problem.
“It Takes a Village” will never be hackneyed, and I certainly agree with the Amen.