Violation of a Laws of Pharmacoeconomics: Cost-Effectiveness (C:E)

A) The Worried Well: A patient is noted to be non-compliant with his psychotropic and anti-hypertensive medications. The anecdotal observation the doctor makes, however, is that, despite the expense, when patients are adherent, they suffer less anxiety, and this translates into less office visits and lower blood pressure. How can you get a win-win out of this?

B) The Ripple Effect ("When the balloon gets squeezed, it will inflates somewhere else.") In the psychotropic / anti-hypertensive scenario, above, the expensive drug used carefully and well means less visits to the ER. In fact, if one looks at the total episode of care (EOC), the drug costs are more than offset by the reduction of expensive services and hospitalizations. Nevertheless, the HMO raises questions about your (the doctor's) per member per month (PMPM) cost because they are looking only at the cost of the Rx, not the EOC. Is there a way to enlighten the HMO on behalf of all physicians in the same plight?

C) The Offset Effect: In a recent study, the not surprising finding was that by increasing the compliance with Beta blocker use in CHF, office visits went up, and the hospitalization rate went down. [Whellan DJ, Laura Gaulden L, Gattis, WA, et al. The Benefit of Implementing a Heart Failure Disease Management Program.Arch Int Med, October 8,2001;161(18):2161-2276]

How can you make the same argument for other types of care--mental health, depression, renal disease, chronic pain syndrome, diabetes, etc.?