HYPE PRICE For hypertensives, there is one other thing in life that's as inescapable as taxes and the tomb-the daily cost of managing their condition.
By Grace Roxas, Contributing Writer
Taking your first hypertension tablet is a rite of passage...to a lifetime of daily pill-popping even after your blood pressure has settled back to normal, or what can pass for normal now that the body's autoregulatory mechanism has partially abdicated to the power of medication. Bert, a mild hypertensive who started medicating four years ago, found this out when his BP level dipped below the threshold and he was advised to just go low on his beta-blocker instead of giving it up altogether. Spending less than PhP5 daily for his half-dose maintenance medicine, he is actually one of the luckier ones for whom the baseline cost of hypertension management is relatively low. Along with quarterly medical consultations and lab exams, his annual spending amounts to less than PhP10,000, a pittance for this 59-year-old thriving businessman whose mild condition does not get in the way of gainful work. Cardiologist Rene Reyes of The Medical City and St. Luke's Medical Center says this regular ounce of control is better than the pound of cure for complications later on. "A lot of times, the blood pressure increases and the cholesterol rebounds if you discontinue the medicine. For a 50-year-old patient for example, who still has around 20-25 years before him, it's less expensive than having a heart attack or a stroke." He adds that a top cause of such serious complications is when patients forget to take their medicine or opt to stop doing so once they feel a little better. Philippine Heart Center's Dr. Gregorio Patacsil estimates that with complications, the basic expense for hypertension goes up by three to five times depending on their nature and severity. "The tragedy is that hypertension is a silent killer. By the time it becomes really symptomatic, it is already irreversible, complicated na."
More often than not, complications are a big factor in real-world hypertension mathematics. Purely hypertensive individuals like Bert comprise only about a quarter of the patients who seek medical help on account of high blood pressure, notes Reyes. Cholesterol problem is a common concomitant condition either with or without diabetes. Bert's wife is one such complicated case. For hypertensive medicines alone, her average monthly spending (PhP3,000) is already about a third of her husband's annual total. A moderate-to-severe hypertensive, she usually takes an angiotensin II antagonist-generally the most expensive class of antihypertensives around at an average cost of PhP50/tablet-in addition to a beta-blocker. Her monthly bill for medication can go up to PhP15,000 since she also takes other medicines to manage her cholesterol level and alleviate hypertension-aggravating conditions like digestive upset and heartburn that are, in turn, side effects of the painkillers she takes for her arthritis. She could be going to the hospital twice a week with an elevated blood pressure as a result of stomach reflux. Two hours in the emergency room of a premier private hospital can cost her PhP3,000 and hospital confinement which happens every other month when her BP reaches a stratospheric 200/100 mm Hg can drain her pockets by another PhP20,000 for a two-day stay. Barring such emergencies, hypertensive patients are normally advised to seek follow-up medical opinion every three months or less, depending on how tractable and complicated their condition is and to check for adverse effects of the medications. At an average of PhP600 per visit, a patient may need PhP2,000 to PhP7,000 annually for consultation fees. Diagnostic procedures require a bigger outlay. A patient, especially someone newly diagnosed, may opt to go for a complete diagnostic work-up, which includes blood chemistry tests, electrocardiogram, chest X-ray, and possibly, an echocardiogram and a treadmill stress test. This whole battery of procedures amounts to about PhP10,000, especially if done in private hospitals. For those with high triglycerides and other concomitant conditions, monthly consultations and quarterly lipid profiling are recommended.
"Serious hypertension can be double jeopardy. Di ka na makatrabaho, gagastos ka pa," says Bert. His wife, who started nursing the condition eight years ago, has stopped working even at desk jobs as even the slightest fatigue and tension can trigger her condition. "In our case, okay lang dahil kumikita ako, but think of those who live hand to mouth and don't have extra to spare for medicine expenses," he adds. If you are a minimum-wage earner in the Philippines who works at a physically demanding trade or at one that is otherwise stressful, a serious-enough bout of hypertension can send both your health and economic prospects crashing. With real hypertensives spending around PhP100 a day for medicines and related expenses, this is already more than a third of the PhP275 daily minimum wage. And depending on how serious and complicated your condition is, blue-collar, isometric activities like carrying weights can put you at risk for strokes and heart attacks. "High blood" woes have also become viciously egalitarian. "We have this mistaken notion na ang nagkaka-hypertension lang ay ang mayayaman, matataba, at masasarap ang kinakain. Pero kahit pobre ka, may stress ka rin. And in essential hypertension, the cause is unknown so there are eight to 10 possible causes or triggering factors which can operate in twos and threes in a hypertensive individual," explains Patacsil. Current medical thinking in the West, he adds, veers toward giving three to four medications for moderate to several essential hypertension. He himself prescribes mono-therapy only for mild cases, and for more serious conditions, usually a combination of either angiotensin II antagonist plus diuretics or beta-blocker plus calcium antagonist. Bert notes that it is actually cheaper and more convenient for some, especially urban white collars with middling income, to eat blood pressure-priming junk food and fast food rather than sit down for a decent, leisurely meal in a good restaurant. In terms of medicine pricing, Patacsil points out that antihypertensives are no exception to the much-belabored fact that drug prices in the Philippines are among the highest in this part of the world, although the off-patenting of many branded originals has given patients cheaper alternatives in recent years. Bert's father-in-law has been daily shelling out, over the past 10 years, as much as PhP150 of his retirement money for his high- blood-pressure therapy. And it's not just because he needs to take his medicine twice daily. The branded calcium antagonist he was taking cost around PhP70 a pop. Health-plan providers tend to tackle hypertension with the tip of a long stick. Aside from the common policy among health-maintenance organizations of not covering any expenses during the first year of membership, the expenses that are eventually shouldered do not adequately cover the regular purchase of medicine, the most financially onerous aspect of hypertension management. Some would cover only the consultation, diagnostics expenses, and medicines used during hospital confinement. Others would set a ceiling of around PhP5,000-an amount equivalent only to approximately two months' supply of medicines for a moderate hypertensive-for annual reimbursement. Even the Philippine Health Insurance Corporation requires at least 24-hour confinement in a tertiary hospital before members can avail themselves of the benefit package for medication and other expenses.
Doctors are not blind to the fact that economic realities have as much to do with their patients' outlook for adequate management. Although Reyes believes that a complete diagnostic work-up is important to cover all bases in managing the condition, he also considers a patient's financial capacity to comply with all the tests. If a patient is young and relatively free from complications, he would usually make do without the expensive 2-D echocardiogram that costs between PhP4,000 and PhP5,000. Having experienced practicing in poorer provincial areas, he also knows a thing or two about what he calls "going clinical" in hypertension diagnosis. "Sa probinsya, magagaling ang mga doktor," he quips. "They go clinical. Wala na kung minsang blood tests, sophisticated echocardiogram, and treadmill. They just prescribe the medicine." As a consultant in a government-run medical center, Patacsil is even more disinclined to make the more expensive procedures a standard part of hypertension diagnosis. "There are only very few reasons that you will need a 2-D echo and the treadmill. The compelling reason is when the condition is severe or complicated." Reyes cautions that economizing on tests for patients who can ill-afford is one thing and dealing with possible complications is another. "In high blood pressure and diabetes, the initial end-organ damage is microscopic. Sa diabetes, if your sugar level is more than 100 and there is family history, you should go for a thorough exam." Financially hard-up patients who need or want to be diagnosed rigorously, may also consider going to independent (i.e. nonhospital-based) laboratory diagnosis facilities where all the work-up procedures are offered at much affordable rates, as much as 50-percent lower than in hospitals. Many of these facilities are located near the perimeter of the hospitals themselves and are said to have comparable quality with hospital-based labs. For medication, Patacsil suggests tips of scrimping on the tabs without sacrificing compliance. Unless contraindicated by the patient's other conditions, he first tries to prescribe a beta-blocker, one of the cheapest classes of antihypertensives around. Patients with patience to tinker around with their medicine may think of buying the highest-dosage preparations and just segmenting each pill as needed. He observes that for a patient needing a five-milligram daily dose, buying a 10-milligram tablet and halving it for a two-day intake will come out cheaper than buying two five-milligram preparations. Finally, if two drugs prove to be just as effective and one is cheaper than the other, the patient should go for the cheaper one. "With our present armamentarium, 85 percent of hypertension cases can actually be controlled and prevented from leading to more expensive complications," he opines. M |
