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ACE inhibitors make financial sense

Dr. Stacie Bering The Spokesman-Review

What if Medicare covered ALL the costs of a particular medication for a particular group of people? Specifically, what if Medicare paid for ACE inhibitors for all those over 65 who had Type II Diabetes? Wouldn’t that be a stupid waste of the taxpayers’ money?

Not so, according to researchers at the University of Michigan and Harvard.

Diabetes is increasing in frequency in the United States, probably because we are getting fatter, and being overweight is a significant risk factor for Type II diabetes. As we boomers get older, there will be more of us collecting Medicare and more of us with diabetes.

It isn’t just the diabetes that’s the problem. Diabetics are at higher risk than the nondiabetic population for other problems like high blood pressure, heart attacks, heart failure, stroke, kidney disease and kidney failure. Twenty-seven percent of Medicare dollars are spent treating diabetes and its complications. Diabetes is an expensive disease.

The cardiovascular and kidney problems associated with diabetes can often result from the high blood pressure that is common in diabetics. The heart has to work harder to get the blood through the vessels, and over time the heart can lose it’s power, resulting in poor blood flow to some pretty vital organs — the brain, the kidneys, and even the heart itself. But the hallmark of diabetes is diseased small blood vessels, and the small vessel disease happens in these precious organs as well, causing problems even if the blood pressure is normal.

ACE (angiotensin converting enzyme) inhibitors work by keeping angiotensin from being converted into angiotensin II — a potent chemical that causes blood vessels to tighten, or constrict. ACE inhibitors cause blood vessels to relax, the heart doesn’t have to work so hard, and more blood and oxygen flow to the heart and other organs.

ACE inhibitors are often used to treat high blood pressure, but even if a diabetic has normal blood pressure, ACE inhibitors help increase blood flow. This is particularly important for the kidneys, virtual masses of small blood vessels, and the theory is that ACE inhibitors somehow work to increase blood flow through these tiny vessels as well. Perhaps this is why studies have shown that ACE inhibitors can delay the appearance of kidney disease, and maybe even reverse its course, even when a diabetic doesn’t have high blood pressure.

The researchers in this study used a computer model, Medicare expense data and drug cost data to model the cost to Medicare of three scenarios: 1) Complete coverage of ACE inhibitors for all diabetics; 2) Coverage with the Medicare drug benefit which will come “online” in 2006, that is, partial coverage; and 3) Current Medicare coverage (i.e. none). They found that not only would the provision of ACE inhibitors to all diabetics decrease cardiovascular disease, kidney disease, and death in diabetics, it would actually decrease program costs to Medicare and allow more dollars for other necessary health care spending for those over 65.

Studies have shown that the cost of medications can cause many Medicare recipients to avoid buying the medications they need. Studies have also looked specifically at Medicare recipients with diabetes and found that they cut their personal costs by avoiding the medications they have been prescribed. I’ve learned over the years that medicine will surely not work if you don’t take it!

The authors of this study point out that in an era when we are told we need to worry about the financial viability of Medicare, “rare opportunities to improve quality (of health care) while also saving money should not be treated lightly.”

I suspect there are other areas of Medicare expenditures where this is true. Let’s hope that the administrators of Medicare stand up and take notice, and encourage more studies of this kind for the common ailments of the “elderly.” (Sixty-five is looking younger and younger to me every year!)

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