Case study #3: The story of Greta Barker

     Greta Barker is the 71-year-old woman with coronary heart disease, congestive heart failure, high blood pressure, diabetes, and high cholesterol mentioned in chapter 1. She remains the poster child for my cost-saving program.

     After her husband passed away, Greta moved from the California Central Valley to live with her sister on the central coast. When she first came to me she was taking 14 different drugs as prescribed by her previous doctors. Unfortunately, with her husband’s death she also lost his comprehensive insurance benefits, including prescription benefits, and confided that she could not afford to buy all of her medicines.  Some were taken intermittently, and others discontinued altogether. Cost for the 14 drugs amounted to $3871 every three months, or $15,484 per year. After an examination, tests, and reviewing all available medical records, I worked with her over the next few months to reduce her prescription burden.  Medicines were carefully weaned, discontinued, or substituted per the cost-saving methods as deemed appropriate with close follow-up. Eventually, we arrived at the regimen below.  Her total number of medicines was reduced from 14 to 7. Heart failure improved (with an increase in diuretics); diabetes, blood pressure, and cholesterol all remained well controlled. Prescription costs (purchased at a discount pharmacy) were reduced to less than $170 per month, a savings of $13,480 per year. Details of exactly how this was accomplished with reference to the cost-saving methods are provided below. 

 BEFORE:

*Average retail price for ninety days’ therapy at the patient’s prescribed dose.

 AFTER:

**Lowest available price of ninety days’ therapy as priced on Drugstore.com.  
                                                                              
Yearly savings:  $13,480

     When Ms. Barker first presented to my office her blood pressure was running low. I reduced her dose of the blood pressure drug Norvasc. This was done for medical reasons more than economic ones. By the second visit I was able to take her off the Norvasc entirely, with improvement in blood pressure and one less expensive drug for her to buy (CSM#1: Eliminate medicines that are no longer needed).  Savings: $230 per quarter.

     Nothing in the medical records or by her history justified the use of Singulair, a second-line treatment for allergies and asthma. It was started by a hospitalist while she was treated for pneumonia and continued by her family doctor after discharge. She was able to stop the drug after the first office visit without consequence (CSM#4: Eliminate medicines that were never needed). Savings: $338 per quarter.

     Advair, (a combination of two inhaled drugs for treatment of asthma and other chronic lung diseases) had also been started by the hospital physician managing her pneumonia. She gave no history of asthma, chronic lung disease, nor had she ever smoked. It may have been given for wheezing associated with her pneumonia.  The medication was continued by her family doctor after hospital discharge. At the time she began to see me, she was using it only intermittently, and without any perceived benefit. Since she noticed no difference without it, I told her to discontinue it altogether (CSM#1: Eliminate medicines that are no longer needed).  Savings: $609 a quarter.

     She also stopped taking the thyroid drug, Levoxyl, when she ran out of it. While I don’t recommend this approach, it did allow me to assess whether the hormone was ever necessary. Blood tests after six weeks without Levoxyl showed her thyroid function to be normal, and the replacement hormone was not renewed (CSM#4: Eliminate medicines that were never needed). 

     Class substitutions were made for Altace (an ACE inhibitor) and Coreg (a beta blocker) with generic lisinopril and metoprolol, respectively (CSM# 11: Insist on cheaper medicines within the same class), lowering her cost for three months of two medicines from $586 to $47. No change in status of her heart disease or blood pressure was seen with the substitutions.

     An inspection of her original list of drugs shows three different drugs all for the treatment of high cholesterol: Zetia, Niaspan, and Zocor. Serum cholesterol was extremely low on the combination (LDL of 33) and beyond the standard goals of therapy. She was advised to stop taking the first two but continue the Zocor (CSM#4: Eliminate medicines that are no longer needed). Cholesterol remained strictly controlled on Zocor alone.  These results persisted with transition to generic lovastatin once the Zocor ran out (CSM#11: Insist on cheaper medicines within the same class). Cost for the three brand name drugs was $1137 per quarter, while she was able to buy generic lovastatin for about $100.  Savings: $1037 per quarter.

     A comprehensive review of her records showed no justification for use of the drug Plavix; she had no history of stroke, TIA, recent heart attack, acute coronary syndrome, or coronary procedures. The drug was discontinued without incident, except for a savings of $456 a quarter (CSM#4: Eliminate medicines that were never needed).

     The most glaring difference in the BEFORE and AFTER lists is in the number of brand-name drugs.  Twelve of the 14 original drugs were expensive patented products. All but one in the AFTER list are generics drugs. Had Ms. Barker. insisted on treatment generic drugs, she might have avoided her financial crisis.  Most of Ms. Barker’s savings came from elimination of unnecessary drugs. While she may not have been sophisticated enough to suggest elimination of these to her doctor, she certainly could have asked her doctor all of the questions listed at the end of chapter 3:

·         What was the original indication for each medication prescribed?

·         How was each diagnosis or medical problem confirmed?  Is each problem still active?

·         Is ongoing therapy still warranted?

·         Has each medication proven itself effective, and is each still effective at the present time?

·         If there is any uncertainty, is a trial discontinuation of any medicine justified?

·         For any medications that were started in the hospital, what were the circumstances?  Is continuing therapy still warranted?

An earnest review of her treatment would have led to elimination of those unnecessary and expensive drugs, saving her over $13,000 per year.

 Post script 
     Eventually, Ms. Barker enrolled in the Medicare prescription benefit program. Her new costs under her chosen plan were further reduced to $293/quarter. Had she remained on her original fourteen medicines, however, her out-of-pocket costs would have been $1148/quarter, almost 4 times as much and well beyond her budget! So joining Medicare Part D alone would not have been a solution to Ms. Barker’s excessive prescription burden, and would not have improved her care as application of the cost-saving methods did.                        
                                                              Back to Cover Page

 

Case study # 1:  The story of Mr. Merton (from introduction)

     Mr. Merton is the 73-year-old retired service station owner discussed in my introduction. His story was the inspiration for this book. When he first came to see me, he was under treatment for coronary heart disease, high blood pressure, and high cholesterol. A stent, or tube, had been placed in two of his coronary arteries following a heart attack 18 months prior. His medication list was as follows:

BEFORE:

Drug	Dose	Cost*
Altace	10 mg daily	$95
Aspirin	325 mg daily	$   1
Coreg	3.125 mg twice a day	$189
Digitek	0.125 mg daily	$ 22
Lipitor	20 mg in PM	$174
Plavix	75 mg daily	$199
Total		$680

*Mr. Merton’s cost for thirty days’ therapy, fall 2004.

     To bring prescription costs within his budget, the first cost-saving method (CSM) applied was CSM#1: Eliminate medicines that are no longer needed. Asking the question, “Is each medicine still indicated at the present time?” we found that the Plavix was no longer necessary. At that time, there were only data to support treatment with Plavix for up to 12 months following coronary artery stent placement.[1] As it had been 18 months since his procedure, the medicine could now be discontinued. This resulted in a savings of about $200 per month and also reduced his risk of bleeding complications.

     Next, we used CSM#11: Use cheaper medicines within the same class. The brand-name ACE inhibitor Altace was substituted with the cheaper, generically available lisinopril. The beta-blocker Coreg was likewise substituted with generic metoprolol. These substitutions are easily determined using the book’s Expensive Drug Survival Index. For Mr. Merton, these substitutions resulted in a savings of $264 per month without any loss of blood pressure control or in protection against future heart attacks.

     Applying CSM#13 (Split tablets) to the dosing of Lipitor resulted in further savings. Rather than taking a single 20 mg tablet per day, he was instructed to take ½ of an 80 mg tablet every other day. He still received 40 mg of the same medicine every two days, but the cost was reduced from $183 to $46 per month. Cholesterol levels remained strictly controlled.

     Finally, Mr. Merton began to shop for the best available price for his medications (CSM#17). These are listed below.  

 AFTER:                              

Drug	Dose	Cost**
Aspirin	325 mg daily	$  1
Digitek	0.125 mg daily	$13
Lipitor	80 mg, ½ every other day	$30
Lisinopril	10 mg daily	$13
Metoprolol	50 mg, ½ twice a day	$  7
Total		$64

**For thirty days’ therapy as priced on Drugstore.com.

Yearly savings:  $7,392

---

[1] There are now data to support the use of Plavix for up to 24 months following implantation of drug-eluting stents.  (JAMA 2007, January 10; Vol 297:159-168)

Case Study #2: Beating the Medicare Coverage Gap

ORIGINAL REGIMEN:

*For one year’s supply at Vera’s prescribed dose.

WITH STANDARD MEDICARE PART D BENEFIT:

AFTER COST-SAVING METHODS:

* For one year’s supply at Vera’s prescribed dose.

 WITH STANDARD MEDICARE PART D BENEFIT:

Yearly savings (beyond Medicare Part D alone, $3331 - $905):  $2426

     When Vera’s family confided that she could not afford her medications—even with the new Medicare prescription benefit program—the cost-saving methods were applied and the following changes were made:

     A careful history revealed that Vera did not regularly take her nebulizer treatments with DuoNeb (which are completely covered under Medicare Part B), putting greater emphasis on Advair (at a cost of $2500 per year) to control symptoms of emphysema. With education, she increased nebulizer treatments to 3-4 times a day, and was able to reduce Advair to once a day. This change not only improved symptoms, but also reduced her medication costs by over $1200 per year. (CSM 14: Get it prescribed right.)

     Further analysis revealed that she had completed a five-year course of Fosamax (long-term studies of Fosamax show no further reduction in overall fractures after five years[2]), which could now be discontinued at a savings of $1032 per year. (CSM 1: Eliminate Medicines that are no longer needed.)

     Finally, Vera began to buy the generic form of Zoloft (sertraline), which proved just as effective at a 95% savings over the brand name. (CSM 10: Insist on generic drugs.) Total yearly prescription costs were reduced to $905, or about $75 per month—well within her budget.