Appropriate Prescribing in a Time of Chaos

Jerry Avorn, MD, Co-director of NaRCAD

As I write this in mid-January, it is difficult to know how the health care system will be transformed in the coming weeks, months, and years. But one thing is clear:  the new administration and Congress are intent on repealing the Affordable Care Act, and they will have the votes in Washington to do so.  Despite their holding this policy position for six years, followed by a long (if issues-light) campaign season, it is not at all clear what will replace it.

​But one thing is certain: the new administration is committed to reducing federal support for health care for enormous numbers of American citizens. “Better coverage and lower costs” is more bumper-sticker rhetoric than plausible policy, and doesn’t meet the basic criteria of arithmetic.

This means that all those who care for patients in the U.S., as well as policymakers, will be forced to live under the yoke of that awful cliché, “doing more with less.”  (Our colleagues in Canada and overseas must be reading this message from the richest nation on earth with a mixture of horror and pity.) Appropriate clinical decision making is about to be transformed from a noble goal we should all strive for to a literal matter of life and death.

​As the ranks of the uninsured and underinsured swell, prescribing a costly drug when a more inexpensive one would work as well will increasingly mean that patients without adequate coverage will simply be unable to afford treatment for their atrial fibrillation, hypertension, or heart failure. The aftermath of the November election will convert a bumpy, imperfect patchwork of coverage into a public administration catastrophe, soon to be followed by a public health debacle. 

These changes will transform the active provision of evidence-based, non-commercial information about clinical care from a smart choice for quality improvement to an urgent requirement. Practitioners who care for the millions of patients whose coverage is legislated away will desperately need the very best information about comparative efficacy and cost-effectiveness.  

---

Most of us engaged in academic detailing programs have shied away from emphasizing cost-containment as a primary feature or goal of such programs, and for good reason. But just as battlefield medicine often has to dispense with the niceties of office practice to address front-line emergencies, we will need to consider the possibility of “battlefield academic detailing” in the coming year to help deal with the widespread health care financial trauma that patients throughout the U.S. will be confronting, along with their health care professionals.

​Most of us in American medicine – patients and clinicians alike – will find our hazard ratios going up, and our quality of life going down. Now more than ever, it will be imperative to communicate the best science as effectively as we can.

---

Biography. Jerry Avorn, MD,​ Co-Director of NaRCAD
Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist, geriatrician, and drug epidemiologist,  he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use, particularly in the elderly. Read more.

---