Beta-blockers for heart failure: who should pay?

The effectiveness of beta-blockers in the treatment of heart failure is now well established (1–5). Historically, however, beta-blockers were contraindicated in patients with heart failure (6); perhaps because of that, gaining their widespread adoption has been especially challenging. A recent study demonstrated that even under ideal circumstances, with nurse facilitators promoting their use, beta-blockers are prescribed to fewer than half of eligible patients (7). Not much is known about the best ways to promulgate findings of efficacious treatments such as beta-blockers into practice, and little is also known about the economic effect of beta-blocker therapy for heart failure. Economic analyses weigh the costs and benefits of one diagnostic or treatment strategy versus one or several others and can be performed from the perspective of various stakeholders. The Panel on Cost-Effectiveness in Health and Medicine recommends that economic analyses take the societal perspective, with the option of considering other perspectives as well (8). The societal perspective reflects the public interest and avoids bias, and, in practice, most economic analyses are conducted from this single perspective. In this issue of The American Journal of Medicine, Cowper and colleagues assess the economic effect of betablocker therapy for heart failure from several alternative perspectives that have not previously been examined, such as the perspectives of society, Medicare, hospitals, physicians, and patients (9). The authors showed that beta-blockers are economically worthwhile, but only from the perspective of society or Medicare, for which the savings generated from fewer hospitalizations more than offset the greater medication costs. Their analysis found beta-blocker therapy to be especially worthwhile for Medicare, with savings of over $6000 per patient treated for 5 years; by not paying for prescription medications, at least until now, Medicare has not had to shoulder any potential increase in medication costs from expanded use of beta-blockers. On the other hand, Cowper and colleagues found that there is an economic disincentive for hospitals, physicians, and patients to adopt beta-blocker therapy. Hospitals would lose about $2600 per patient because of fewer admissions for heart failure, physicians’ revenues would decline by about $427 because of lower inpatient revenues, and patients would suffer greater outof-pocket costs. Thus, by examining many perspectives, the analysis by Cowper and colleagues highlights the economic conflict facing many patients and physicians. Although patients with heart failure generally benefit clinically from taking beta-blockers, instituting betablocker therapy is not always as easy as just writing a prescription. It can be difficult and time consuming to titrate the dose of beta-blockers; Ansari and coworkers have shown that it takes, on average, at least 6 months to titrate patients’ dosages (7). Also, side effects are problematic for some patients, and, as emphasized by Cowper and colleagues, patients may not be able to afford to pay for yet another medication. Yet even when treatment is indicated and affordable, physicians may not prescribe a new therapy for many reasons, including prior beliefs, lack of time, or, less likely, some ulterior financial motive. The challenge is to promulgate the salutary clinical trial findings and at the same time align the various perspectives so that there is no conflict in prescribing and filling beta-blocker prescriptions for the treatment of heart failure. One way to enhance medication affordability is to provide a prescription drug benefit to patients. Such a plan would shift some of the cost of beta-blocker therapy from the patient to society or to Medicare, the institutions that would benefit economically from increased use of beta-blockers. In November 2003, Congress enacted a Medicare prescription drug benefit. The benefit will not take full effect until 2006, and even then, in many cases, beneficiaries will have to bear a sizable proportion of the cost of prescription drugs (10). Still, for the reasons stated, it is commonly thought that the new Medicare prescription drug benefit will improve medication adherence and, thereby, the health of seniors, including those with heart failure . . . but will it? Paradoxically, a recent study by Craig and colleagues, using data from the Medicare Current Beneficiary Survey, demonstrated that only about 3% of elderly patients do not fill their prescriptions, with no difference in prescription filling rates between patients with supplemental insurance and those without (11). Those findings suggest that the cost of medications has not been a barrier to adherence in the elderly and that a prescription drug benefit would be of little help in increasing adherence. Other findings from the Medicare Current Beneficiary Survey have demonstrated that Medicare beneficiaries who have supplemental prescription drug coverage fill 25% more prescriptions than do those who have no supplemental drug coverage (12). How can one reconcile those data with the data of Craig and colleagues? If elderly Am J Med. 2004;116:135–136. From the Department of Internal Medicine and the Institute for Health Policy and Health Services Research (DPS, JT), and the Cincinnati Veterans Affairs Medical Center (JT), Cincinnati, Ohio. Requests for reprints should be addressed to Joel Tsevat, MD, MPH, Section of Outcomes Research, University of Cincinnati Medical Center, 231 Albert Sabin Avenue, Cincinnati, Ohio 45267, or joel. tsevat@uc.edu.