One of the biggest and most contentious issues in managing the health of populations, whether insurance plan members or employees, is sure to be that related to whether, when, how much, and who should pay for medications useful in promoting health. For sickness care, this has mainly become an argument over which medications are “experimental”, and preference among payers for generics vs. more expensive brand name alternatives. In health management, it is likely to be far more complicated.

A recent article in the UK noted that lifestyle changes are at least as effective in controlling blood glucose levels among those with diabetes or at risk therefor. Choosing to take drugs for the same purpose means “…turning healthy people into patients and the risk of side effects.” It also: “…would send the wrong message to people – that they could reduce their risk without making lifestyle changes.” [“Anti-Diabetes Pills ‘Unjustified’” BBC News Apr 26, 2007]

The growing popularity of “metabolic syndrome” and preference for medications to treat it vs. lifestyle change has disturbed providers and payers alike in many countries. It often involves the use of multiple medications, since it combines overweight, high blood pressure, glucose and cholesterol levels. Yet often enough, exercise that includes strength training, along with diet adjustments can reverse this syndrome, with virtually no costs, though it requires permanent changes for permanent protection. [C. Tzar “Drugs a Poor Solution When the Culprit is Lifestyle” The Australian Feb 24, 2007 (www.theaustralian.news.com.au)]

In the US, bariatric surgery is increasingly chosen to treat people who are severely obese. Celebrities have endorsed this method, describing and demonstrating their own success. Television commercials for such surgery compete with commercials on the vast number of often unproven “nutriceuticals” offered to enable people to lose weight. But such surgery is very expensive, entails serious risks, and requires lifetime adherence to healthier lifestyles to retain its benefits. Often payers require a “trial” of lifestyle changes before they will cover such surgery. [J. Krasner “Tufts Plan Will Restrict Surgery for Obesity” Boston Globe Feb 14, 2007 (www.boston.com)]

For a number of diseases, medications or other treatments seem to be the only solution. Asthma, for example, usually involves both ongoing use of medications to prevent crises, and other medications to treat crises once they arise. A number of chronic pain conditions can be managed best with the use of drugs, though sometimes over-the-counter low-cost options work well. On the other hand, sometimes a drug can be effective, but is unappealing to pharmaceutical firms, either because it is needed by too few (“orphan drugs”), or costs so little and can be produced by anybody, so cannot command a profitable price. [D. Heckbert “New Drug to Fight Cancer May Get the Cold Shoulder” ChicagoTribune.com Feb 27, 2007]
Implanted devices are another form of “medication” that can be used in treating risk conditions. A “diet pacemaker” has been successfully tested, for example, enabling people to lose and control weight without requiring lifestyle changes, by blocking “hunger nerves” for a selected length of time daily. [“Diet Pacemaker May Change Weight Loss” TheAge.com.au Feb 9, 2007] Such an approach relieves patients of even having to remember to take daily medications.

A similar implantable solution has enabled patients with serious heart problems life both longer and more active lives. Implantable cardioverter-defibrillator (ICD) devices were placed in patients with increased risk of abnormal heart rhythms, though no prior history thereof. Not only were patients highly satisfied with the device used, but they reported a “…quality of life consistent with the average Americans their age…” [“Penn Study Finds ICD Devices Offer Heart Patients Life-Saving Benefits and Excellent Quality of Life” Penn Medicine Apr 5, 2007 (www.uphs.upenn.edu)]
When people pay for a “medication” solution rather than the “motivation” alternative of making permanent lifestyle changes, it can be argued that such is their right in a free society. But when insurance or government payors cover the medication option, they are spending other people’s money. With pharmaceutical firms naturally preferring the medication option, since it creates a lifetime dependence on the drugs involved, it is mainly payers and patients who must weigh the options carefully.

It is common to define “health” as not merely the absence of disease or injury, but positive physical, mental, social and spiritual wellness, including the absence of dependence on medications to maintain such a status. Dr. Dean Ornish, for example, champions lifestyle changes as ways to “reverse” diabetes, heart disease, and even prostate cancer. [“PRMI – The Preventive Medicine Research Institute” (www.prmi.org) May 5, 2007)]

Lifestyle changes are certainly the preferred approach to losing and maintaining a healthy weight, but they are also effective in controlling blood pressure and cholesterol. They yield positive health and life quality side effects compared to the usually negative side effects of drugs, to say nothing of their costs. And they automatically add positive impact on most people’s self-esteem, self-efficacy, and self-image, since people who succeed in achieving health goals via lifestyle changes can take the credit for doing so, rather than thank medications for the results.
Of course, lasting lifestyle changes are more often achieved with help, and such help also costs money – to patients or third party payers and thereby employers, taxpayers, etc. Almost all disease management, risk reduction and health promotion efforts require lifestyle changes, and therefore the enthusiastic and continuous cooperation of “patients”, just as most medications solutions require continuous “compliance” with respect to taking the medications correctly. But at least people making lifestyle changes in order to achieve health goals can reach the point where they are fully “reformed”, and need no more support from sources that cost money, except in occasional relapses.

Given the widespread preference of a “magic pill” to prevent as well as cure disease, consumers will likely be part of the problem as well as part of the solution when it comes to the medication vs. motivation issue. Decades of advertising has conditioned most consumers to think of the medication alternative. Of course, as people recognize an increasing number of “diseases” for which there are medication treatments, and are increasingly using their own money to pay for such treatments, they may more frequently have to consider the trade-offs between relying on medications vs. their own efforts.

Already, employers are supporting medications when they help to manage a chronic disease or risk condition, often by reducing or eliminating out-of-pocket deductible or co-payment obligations for such medications. Combined with the Medicare Part D prescription drug benefit, such coverage can insulate most people from the costs of “preventive” drugs, though not as well from “treatment” drugs. The issue of “medication vs. motivation” is likely to remain a contentious one for individuals as well as payers as long as both are options in achieving health management goals, and as long as payers, as well as patients, have to share the cost burden for their use.