Free Drug Could Sweeten Life for Diabetics

By providing free drugs called ACE inhibitors to people with diabetes, Medicare would both save money and save lives, researchers say. Even if officials don't agree, the upcoming Medicare drug benefit might at least get these valuable therapies into the hands of a few more seniors in need.

As any critic of pork-barrel politicians will tell you, there's no such thing as a free lunch. But after crunching the numbers, researchers at the University of Michigan Health System (UMHS) think they might have found something that comes close. According to their analysis, treating seniors with diabetes to complimentary prescriptions of a heart-saving medication called an ACE inhibitor would not only benefit the recipients, but ultimately save Medicare money as well.

According to the National Institutes of Health, 10% to 20% of people over the age of 40 have diabetes. Almost two-thirds of these people will die from heart attacks or strokes, and many will suffer kidney failure and end up on dialysis machines or on the transplant list. All of these complications cost money, and for seniors or those without private health insurance, that means Medicare and taxpayers are picking up most of the tab.

"The economic cost of a heart attack once it's happened is dramatic," says pharmacologist Domenic Sica of Virginia Commonwealth University Medical School in Richmond. The American Heart Association estimates the U.S. cost of heart failure in 2005 at $27.9 billion. "But if we can treat in anticipation of and delay the onset of a heart attack, then there's a substantial economic gain," Sica adds.

Internist Allison Rosen of UMHS in Ann Arbor wondered how much of an economic gain could be realized by cutting the cost of a single preventive therapy. She and her colleagues focused their attentions on ACE inhibitors. These drugs--formally known as angiotensin-converting enzyme inhibitors--reduce blood pressure by preventing production of angiotensin II, a protein that constricts blood vessels. High blood pressure puts people at risk for heart attacks and strokes. Diabetics are additionally prone to kidney failure because their elevated blood sugar concentrations and increased cholesterol quantities damage the tiny blood vessels marbling the kidneys. Studies have shown that ACE inhibitors reduce diabetics' risk of heart attacks, strokes, and death by at least 25%, and cut death by kidney failure by upwards of 50%.

But fewer than half of diabetics with Medicare as their health insurance use the drugs, says Rosen. "One of the things that really creates a barrier to using these really effective medications is out of pocket costs," she says. Even if people have supplemental insurance covering part of prescription costs, "patients who face co-pays use less of those medications," she says. Taking ACE inhibitors can cost patients about between $200 and $300 a year. And with preventive drugs being "grossly underutilized," hospitalizations and deaths due to heart attacks and strokes are on the rise, reports cardiologist Gregg Fonarow of the University California, Los Angeles, in the August issue of The American Journal of Cardiology. Hospital stays for heart failure rose 157% from 1979 to 2002, he says.

Research shows that cost is a major factor in prescription drug use, and lowering the price tag of medications keeps more patients on them. So Rosen asked how the savings proposed under the government's new prescription drug plan might translate into increased usage. Starting in January 2006, Medicare plans on covering about one-third of out-of-pocket costs for ACE inhibitors for seniors who pay the premium to sign up for the plan. Rosen fed that information into a computer program that also considered such factors as how effective ACE inhibitors are in preventing heart attacks and slowing kidney disease, the costs of hospitalizations, and the cost of the drugs, and other situations that go hand-in-hand with diabetes. She found that with Medicare's new drug benefit, about 7% more diabetics might take the drugs. What's more, if Medicare absorbed the entire cost of ACE inhibitors, Rosen figures an additional 20% of diabetics would line up for the drugs. Rosen and her colleagues published their findings in the 19 July issue of Annals of Internal Medicine.

Even footing the whole bill for each and every recipient, Medicare would save money in the long run by reducing the need for treating diabetic complications. If the maximum number of anticipated participants signed up--60% of the people who actually need the drugs--Medicare could save on the order of $1600 per patient. But according to Rosen's calculations, Medicare would recoup more than it shelled out even if the number of diabetics lined up for free ACE inhibitors jumped by only 7%, demonstrating that a mere handful of drugs has the potential to reduce medical costs dramatically, she says.

Part of the reason that Medicare could save money by spending money on ACE inhibitors for people with diabetes, says Rosen, is "the drugs are used in a population that tends to have very bad things happening: Diabetics have strokes, heart attacks, and kidney disease at much higher rates than other people." So stopping these expensive events from occurring produces a much greater savings than what would be garnered in the general population.

"This is a big league analysis," says Sica. "This is not single-A ball. And it seems to be grounded in reality." Fonarow agrees: "Rosen's article makes a compelling case that these medications should be provided free of charge." But he doesn't stop there. "The case could be made," he says, "to pay patients to actually take the medications." Rosen agrees. "You could pay people $230 a year to take ACE inhibitors, and Medicare would break even," she says.

UMHS Policy researcher and internist Mark Fendrick, one of Rosen's co-authors, says the study highlights the advantages of revamping how co-pays for all prescription drugs are determined--whether state-sponsored health care or private insurance is covering the rest of the cost. If co-pays were determined by the drug's relative health benefits rather than as a certain percentage of its retail price, lives would be saved and in some cases, money as well, Fendrick says. For example, he says, drugs such as ACE inhibitors that cut the risk of heart attack should cost people less than remedies that alleviate heartburn. And such a policy would guarantee that the maximum number of people, regardless of their income, would have access to life-saving medications.

A representative of the U.S. Centers for Medicare and Medicaid Services says that Medicare is not currently planning on providing ACE inhibitors or any medications for free. That's a shame, say researchers: In this case, politicians might actually be able to offer their constituents a free lunch that would keep recipients in good health and save the government money.

Mary Beckman is a freelance writer in southeast Idaho who wishes that lunch and satellite TV were free.