For those new to me and my ramblings, I am a primary care doctor in a sliding scale community clinic situated in a medium sized community hospital. I have worked a number of practice settings, including the large teaching hospital where I trained, a small rural hospital owned practice, a small physician owned private group, and now a large community medicine organization.
In the endless parade of political angst circulating on Facebook, today we see This Article and This Rebuttal.
The first article basically says that workers in the medical field are all overpaid. While presenting inaccurate statistics and naive claims about the market, the author does make one crucial point. Doctors have been off limits when responsibility is assigned in our horrendous excuse for a health system. The article is eliciting a number of angry responses with the second doctor's being one of the higher profile. The original article's ignorance about the economics of the medical field make it easy pickings.
But that one point lingers. What is the role of the doctor in the health care debate?
Doctors exert power through the orders they write. When we choose one medication over another, prefer a specific type of testing, or direct where a procedure is done, we control the flow of enormous sums of money. Certain orders have more consequence than others. Some realms (radiologic testing and surgeries being a typical example) are known profit centers. Others (such as ICU stays) are known loss centers. The amount of money flow a doctor controls is easily 5-10 times his or her salary. Systems with interests both at the office and hospital level will take losses on salary to retain a physician whose orders then net a profit in orders. This is a key point, one that makes much of the first article irrelevant. i.e. Salaries aren't the issue. Patterns of orders, and the resulting flows of money, are the issue.
There are numerous laws trying to prevent conflicts of interest and outside influence on a doctor's medical decision making. The blatant trips and bribes of the past have been drastically reduced, and there are restrictions of self-referral. However, the basic fashion in which the majority of physicians are paid inherently drives up cost. Most physicians are compensated with a formula involving some base pay and a production factor. The specifics and ratios vary widely, but the production aspect is central. For a self-employed physician, there is no base. This would seem to make sense from a market perspective. However, production is almost always measured in number of patients seen or procedures performed. The more people I see (the less time I give each one) the more I get paid.
The implications range from obvious to scary. Obvious is the much lamented 3 minute visit where the doctor doesn't seem to listen. Troubling is intentionally having patients return more frequently just to boost revenue. When we up the ante to surgical procedures, we get assembly line surgeries and at worst performing unnecessary surgery and overestimating illness as an excuse.
The part that most outsiders don't know about is how much power these choices create, not in terms of personal salary, but in influence in the medical system. A doctor (or group) that does a high volume of surgery can make or break hospitals by choosing one site over a rival. Rules are often bent for revenue producers, abuses ignored. Those that might be in a position to curb behavior as it heads into unethical territory have a vested interested in taking no action. Colleagues are loathe to take action lest their own practices be scrutinized.
The only real control on this is a patient walking out the door and choosing a different doctor. Unfortunately, this process involves numerous barriers and will actually be the subject of an entire future blog entry. Suffice it to say, that the patient doesn't have enough knowledge or choice to exert meaningful market forces. Quality controls and measures are increasingly being attempted, but for the most part these are bureaucratic wastes of time and do not capture the behaviors that are truly draining our system.
The incidence of criminal fraud to increase services and revenue is low but not zero. However, many doctors hover the line of ethics and it is very profitable to do so. While the author of the first article complained about salaries of primary care physicians at $200k and specialists at $350k, a doctor who pushes the system to the limit can make in excess $350k as a primary care doctor and well above $500k as a specialist. Sadly, my experience is that some of the assembly line docs actually are some of our brightest colleagues when a difficult case arises. Most have brilliant rationalizations for their practice patterns. Few admit to themselves, let alone out loud, that they are pushing the line.
Many topics in the health care debate have been untouchable, and I've only brought up a few here. To be clear, I do not think doctors are the root problem. But they are part of the system that IS the root problem. Some doctors are actively trying to change this system and try desperately to avoid the pitfalls I've described. But even those activitist docs are stuck in the systemic bind our profit-based system creates. Whether doctors created or are victims of the system doesn't matter now. The doctor and his or her choices are a significant sustaining force for this dysfunctional system, and cannot be ignored if we are to create something better.
Friday, August 3, 2012
Friday, January 27, 2012
Win Win Win
I have been on a binge of hippy dippy economics books lately, and the term "Gift Economy" is batted around quite a bit. The central idea is that one does good for others without expectation for any direct return. Instead, if you see a need, you help relieve it. Later when you have a need, others will help you. Pay It Forward, What Goes Around Comes Around, etc. One of the hopes is that since needs are met specifically, without dickering or acquisition, that resources are efficiently distributed. In addition, there is a profound effect living under this system has on how people feel about their place in the world.
In contrast, monetary systems make transactions numeric, self-focused, and are necessarily inefficient because of the time and effort to arrive at a price arrangement. That is, once money is involved, transactions tend toward zero sum propositions, or worse. (Certainly, monetary exchanges can be mutually beneficial, but introducing money can at best and usually hinders making an interaction "win-win.") At worst, money encourages relationships that are parasitic or predatory.
Our entire world has become increasingly digitized, monetized, and standardized, and many of the "advancements" of our current civilization are dependent on that fact. Standardization of medical practice is in my mind a very good thing. National Guidelines, Best Practices, Clinical Pathways, are all excellent tools that do improve care when applied appropriately. However, the "number-izing" of our lives has made us assume that everything is Zero Sum when best case scenario is instead a "win-win."
How does this apply to Better Medicine? This is the problem I've been asking myself over and over these last weeks.
The first and perhaps most important application is the most difficult. It is simply the switch in internal motivation back to the helping orientation that sends almost all into the medical field in the first place. When I walk into a room, first and foremost I need to think "What is this person's need?" and "How might I be able to help?" Most patients assume that is what is on my mind or are angry because they know when it is not. In medical school, we are taught to think about diagnosis and treatment and by the time one has finished at least 7 years of repeated practice and review, this is successfully instilled. The part of our behavior that is shaped is what is measured and reviewed.
Similarly, once a doctor is out in practice, what is reviewed is most commonly number of patients seen, money flow, and at best clinical outcomes that are almost always numeric measurements. "Patient Satisfaction" is occasionally measured. As a result, providers are conditioned to think about these items more and more as they progress in their careers. Lawsuits also weigh on nearly ever provider's mind, which further make the doctor-patient relationship at least more distant and at worst frankly confrontational. This group of disconnects is as much a part of the collective dissatisfaction with American medicine as the cost burdens, in my opinion.
We must create a system where our first question is "How can I serve this person's need?" This is basis of the gift economy. The answer will overlap frequently with diagnosis and treatment, and yes sometimes with questions about cost. We must make it easier for the provider (whether doctor, front desk, or nurse) to not worry about what is coming back to them. They need to feel safe that as long as they are caring for the patient's needs to the best of their ability, they will be safe and taken care of.
How do we make the human interaction of caring for the ill truly a win-win? How do we change the perception of the sick toward fellow humans in needs instead of a potential market? How do we take fear out of being a provider?
Maybe we start by seeing our interactions as gifts instead of purchases.
In contrast, monetary systems make transactions numeric, self-focused, and are necessarily inefficient because of the time and effort to arrive at a price arrangement. That is, once money is involved, transactions tend toward zero sum propositions, or worse. (Certainly, monetary exchanges can be mutually beneficial, but introducing money can at best and usually hinders making an interaction "win-win.") At worst, money encourages relationships that are parasitic or predatory.
Our entire world has become increasingly digitized, monetized, and standardized, and many of the "advancements" of our current civilization are dependent on that fact. Standardization of medical practice is in my mind a very good thing. National Guidelines, Best Practices, Clinical Pathways, are all excellent tools that do improve care when applied appropriately. However, the "number-izing" of our lives has made us assume that everything is Zero Sum when best case scenario is instead a "win-win."
How does this apply to Better Medicine? This is the problem I've been asking myself over and over these last weeks.
The first and perhaps most important application is the most difficult. It is simply the switch in internal motivation back to the helping orientation that sends almost all into the medical field in the first place. When I walk into a room, first and foremost I need to think "What is this person's need?" and "How might I be able to help?" Most patients assume that is what is on my mind or are angry because they know when it is not. In medical school, we are taught to think about diagnosis and treatment and by the time one has finished at least 7 years of repeated practice and review, this is successfully instilled. The part of our behavior that is shaped is what is measured and reviewed.
Similarly, once a doctor is out in practice, what is reviewed is most commonly number of patients seen, money flow, and at best clinical outcomes that are almost always numeric measurements. "Patient Satisfaction" is occasionally measured. As a result, providers are conditioned to think about these items more and more as they progress in their careers. Lawsuits also weigh on nearly ever provider's mind, which further make the doctor-patient relationship at least more distant and at worst frankly confrontational. This group of disconnects is as much a part of the collective dissatisfaction with American medicine as the cost burdens, in my opinion.
We must create a system where our first question is "How can I serve this person's need?" This is basis of the gift economy. The answer will overlap frequently with diagnosis and treatment, and yes sometimes with questions about cost. We must make it easier for the provider (whether doctor, front desk, or nurse) to not worry about what is coming back to them. They need to feel safe that as long as they are caring for the patient's needs to the best of their ability, they will be safe and taken care of.
How do we make the human interaction of caring for the ill truly a win-win? How do we change the perception of the sick toward fellow humans in needs instead of a potential market? How do we take fear out of being a provider?
Maybe we start by seeing our interactions as gifts instead of purchases.
Friday, January 20, 2012
The Big Plan
I have been anticipating laying out "the big plan" for a better health care system since I started this blog, and I've started this particular column several times this week. Over those several false starts, I discovered that my ideas really weren't that revolutionary at all. The more I dig, I'm realizing that stealing bits and pieces of other countries' health care policy really isn't the final solution. At the same time, I feel a need to explain where I wished health reform would have gone first in 1992 and then in 2010. Then I can explore moving past those not-so-new ideas.
The Big Plan - 2009-2011 version.
1. A publicly funded and administered safety net that everyone pays into based on income, and all can access.
2. A private system for those who have paid their share but want access to services the public system does not offer.
Our present school system is a perfect example of this idea. We all pay taxes, we can all go to a public school. We can choose private if we want something different. The British medical system is designed this way but in reality the proportion using public care is higher than I envision in the United States. The VA system now is functioning much in this fashion, with most savvy vets using their benefits for many basic functions and hospitalizations but turning to private doctors when they don't get satisfaction.
I advocate for the least number of middle men between the public's money and the actual delivery of care. A specific health system tax (like our Medicare taxes now) and public health services best achieve this goal, and also represent the simplest way to deliver care to the entire populace. The most legitimate criticism, in my mind, is that these kind of systems are notoriously inefficient. The other is that we can't afford the tax burden of paying for such a system. The latter claim is shaky at best, for all other first-world systems of this sort actually operate at significantly lower per capita cost, often with greater access to both providers and technology.
I believe(d) that because this basic plan already existed in other sectors of American life, that we as citizens would be willing to give it a try in health care too. I was wrong. There were voices during the debate pushing for just this kind of model. But at the height of the Tea Party's influence, the phrase "Evil Socialist," as stupid as it was as an argument, did have significant political power. So we got what I'd argue is the worst kind of hybrid system, a publically mandated use of private providers. Not publically supported, which is dicey but has proven to work in some areas, but publically mandated. For a free market to work, you must have choices, including the reasonable ability to opt out completely. That way a business offering terrible product can simply fail. (Similarly, if you are going to apply free market ideas to social problems, you must be ok with people dying as a result of market competition. Many capitalists believe this but know it won't fly well to say it out loud.)
Two weeks into my "save the world" binge, and I've already realized this kind of political dialogue isn't where we're going to find the solution. First we must reconcile the fact that our economy (the basic framework in which we deal with fellow humans) is at this time competition and scarcity based on all but the smallest scales. Not only is this at odds with an industry that is about helping others, it doesn't work well in that context, and makes false assumptions about the endeavour in general.
Proper health care isn't a scarcity. Because the #1 determinant of patient satisfaction (manifest most basely as avoiding lawsuits), outcomes, and professional satisfaction, is that quality of the patient-provider communication. This resource is not quantifiable, and therefore not easily priced. It is not a zero-sum transaction and in fact often follows positive feedback increase.
This is where I'm going next...thinking about an actual paradigm shift.
The Big Plan - 2009-2011 version.
1. A publicly funded and administered safety net that everyone pays into based on income, and all can access.
2. A private system for those who have paid their share but want access to services the public system does not offer.
Our present school system is a perfect example of this idea. We all pay taxes, we can all go to a public school. We can choose private if we want something different. The British medical system is designed this way but in reality the proportion using public care is higher than I envision in the United States. The VA system now is functioning much in this fashion, with most savvy vets using their benefits for many basic functions and hospitalizations but turning to private doctors when they don't get satisfaction.
I advocate for the least number of middle men between the public's money and the actual delivery of care. A specific health system tax (like our Medicare taxes now) and public health services best achieve this goal, and also represent the simplest way to deliver care to the entire populace. The most legitimate criticism, in my mind, is that these kind of systems are notoriously inefficient. The other is that we can't afford the tax burden of paying for such a system. The latter claim is shaky at best, for all other first-world systems of this sort actually operate at significantly lower per capita cost, often with greater access to both providers and technology.
I believe(d) that because this basic plan already existed in other sectors of American life, that we as citizens would be willing to give it a try in health care too. I was wrong. There were voices during the debate pushing for just this kind of model. But at the height of the Tea Party's influence, the phrase "Evil Socialist," as stupid as it was as an argument, did have significant political power. So we got what I'd argue is the worst kind of hybrid system, a publically mandated use of private providers. Not publically supported, which is dicey but has proven to work in some areas, but publically mandated. For a free market to work, you must have choices, including the reasonable ability to opt out completely. That way a business offering terrible product can simply fail. (Similarly, if you are going to apply free market ideas to social problems, you must be ok with people dying as a result of market competition. Many capitalists believe this but know it won't fly well to say it out loud.)
Two weeks into my "save the world" binge, and I've already realized this kind of political dialogue isn't where we're going to find the solution. First we must reconcile the fact that our economy (the basic framework in which we deal with fellow humans) is at this time competition and scarcity based on all but the smallest scales. Not only is this at odds with an industry that is about helping others, it doesn't work well in that context, and makes false assumptions about the endeavour in general.
Proper health care isn't a scarcity. Because the #1 determinant of patient satisfaction (manifest most basely as avoiding lawsuits), outcomes, and professional satisfaction, is that quality of the patient-provider communication. This resource is not quantifiable, and therefore not easily priced. It is not a zero-sum transaction and in fact often follows positive feedback increase.
This is where I'm going next...thinking about an actual paradigm shift.
Wednesday, January 18, 2012
Hybrid Vigor?
At the heart of the health care debate is a conflict that defined much of the 20th century - capitalism vs. socialism. Free market advocates have been pushing for increasing privatization while many in public health sectors are pushing for a single-payer nationalized system. Sadly, these discussions devolve into alternate screaming of "Evil Socialist" and "Evil Capitalist" which obviously accomplishes nothing but to raise collective blood pressure.
I personally believe that this is a false ideologic argument. Pure socialist and pure free market systems never existed, and neither are functional in our highly economically stratified culture anyway. Just as humans have both individual and social aspects to their identities (and flounder if either is ignored), our systems must have public and private components. This is especially true when considering how to provide health care to a population. A good article covering some of the complexities of private vs public health care can be found here:
http://economix.blogs.nytimes.com/2009/05/08/what-is-socialized-medicine-a-taxonomy-of-health-care-systems/
A purely socialized system would mean that taxes are paid to the government and the government administers all forms of health care delivery without other options. Purely privatized systems would have for-profit entities providing care to those who were able to pay the market determined price and those who couldn't would simply go without. No one is seriously proposing either. We're going to have a hybrid system. Get over it.
Now hybrid systems can be good and bad, but when we get together to hammer out the details that will make the system work, rather than yelling at each other about ideology, we might actually get something accomplished. That's where I'm going next.
I personally believe that this is a false ideologic argument. Pure socialist and pure free market systems never existed, and neither are functional in our highly economically stratified culture anyway. Just as humans have both individual and social aspects to their identities (and flounder if either is ignored), our systems must have public and private components. This is especially true when considering how to provide health care to a population. A good article covering some of the complexities of private vs public health care can be found here:
http://economix.blogs.nytimes.com/2009/05/08/what-is-socialized-medicine-a-taxonomy-of-health-care-systems/
A purely socialized system would mean that taxes are paid to the government and the government administers all forms of health care delivery without other options. Purely privatized systems would have for-profit entities providing care to those who were able to pay the market determined price and those who couldn't would simply go without. No one is seriously proposing either. We're going to have a hybrid system. Get over it.
Now hybrid systems can be good and bad, but when we get together to hammer out the details that will make the system work, rather than yelling at each other about ideology, we might actually get something accomplished. That's where I'm going next.
Friday, January 13, 2012
One Terrible Plan for Universal Health Care - and the Seeds of Something Better
Before proposing a basic layout for improvements on the health care system, first we need to ask ourselves "What isn't working in the system we have now?" Though there are many many possible issues, this is what I'd consider the Big 3.
1. According to multiple measures, our health outcomes are not good. Life expectancy in the U.S. is 78.3 years, ranked 36th by the U.N. (#1 Japan is 82.6) Infant mortality is 7 per 1000 live births, 34th. (#1 Singapore is 2.6) We've all seen these statistics before. They're not subtle.
2. Our costs are extremely high ($8,400 per capita, 17.9% of GDP in 2010), in fact the highest in the world. Japan was spending below $3000 in 2007 when the U.S. was spending over $7000. (While kicking our rears in measurable results.)
3. A large proportion of the population has minimal access to health care. (I was very careful in the wording of this statement, I'll return to why.) 50 million people, or 16.7% of the population, are completely uninsured. 27 million of those are working and 10 million are children.
It may seem like a tautology, but I would argue that the #1 priority of a health care system is to improve the health care of those who use it. We would be having a very different conversation in the United States if we were both #1 in health metrics and spending. But we're not. The old saying goes that the system is perfectly designed to get the results it produces. Our system must be designed to produce in the area we are #1 - spending. That is, our system is designed to move massive amounts of money around and it succeeds marvelously. I'll let that simmer a bit. Remember the "pot of gold" from an earlier entry.
Back to my careful wording in #3. When I say that "a large proportion of the population has minimal access," I specifically mean not zero. There is a safety net in place already in the United States, EMTALA. Since 1986, all persons are entitled to evalutation and stabilization in any Emergency Room of a hospital that accepts money from Medicare or Medicaid, regardless of age, race, religion, nationality, ethnicity, residence, citizenship, or legal status. "Stable" is broadly defined such that simple triage does not fulfill a hospital's obligation.
Thanks to EMTALA, we have de facto Universal Health Care now.
This isn't some convoluted technicality. Americans are currently using Emergency Rooms as de facto public health care, in enormous volume. Everyone involved agrees that this is both extremely costly and delivers low quality care (except in the true emergencies that the departments are designed for.) Unless we are going to repeal EMTALA (no politician would dare have that vote on their resume), we are stuck with Universal Health Care.
To be clear, we all are paying out the nose for this horrid form of Universal Care through cost shifting. Hospitals overcharge for virtually every service, in part to compensate for losses caring for the uninsured as required by EMTALA. The cost savings at standalone radiology and surgery centers comes mainly from cherry-picking the high revenue services and avoiding care for those without coverage. But this in turn forces hospitals to overcharge for their services even more. This cycle is at the center of our crisis as a whole, and absolutely affects even those of us with "good insurance."
We have to build a better safety net. Even we (proverbially individualistic and selfish) Americans won't stomach going completely bare. Next post is about what that might look like. The following is my personal framework, but if you're reading this, I welcome other's input before I write that entry.
1. A bare-bones public plan that all citizens pay in on a sliding scale, and covers everyone.
2. A private system of supplemental coverage and services.
1. According to multiple measures, our health outcomes are not good. Life expectancy in the U.S. is 78.3 years, ranked 36th by the U.N. (#1 Japan is 82.6) Infant mortality is 7 per 1000 live births, 34th. (#1 Singapore is 2.6) We've all seen these statistics before. They're not subtle.
2. Our costs are extremely high ($8,400 per capita, 17.9% of GDP in 2010), in fact the highest in the world. Japan was spending below $3000 in 2007 when the U.S. was spending over $7000. (While kicking our rears in measurable results.)
3. A large proportion of the population has minimal access to health care. (I was very careful in the wording of this statement, I'll return to why.) 50 million people, or 16.7% of the population, are completely uninsured. 27 million of those are working and 10 million are children.
It may seem like a tautology, but I would argue that the #1 priority of a health care system is to improve the health care of those who use it. We would be having a very different conversation in the United States if we were both #1 in health metrics and spending. But we're not. The old saying goes that the system is perfectly designed to get the results it produces. Our system must be designed to produce in the area we are #1 - spending. That is, our system is designed to move massive amounts of money around and it succeeds marvelously. I'll let that simmer a bit. Remember the "pot of gold" from an earlier entry.
Back to my careful wording in #3. When I say that "a large proportion of the population has minimal access," I specifically mean not zero. There is a safety net in place already in the United States, EMTALA. Since 1986, all persons are entitled to evalutation and stabilization in any Emergency Room of a hospital that accepts money from Medicare or Medicaid, regardless of age, race, religion, nationality, ethnicity, residence, citizenship, or legal status. "Stable" is broadly defined such that simple triage does not fulfill a hospital's obligation.
Thanks to EMTALA, we have de facto Universal Health Care now.
This isn't some convoluted technicality. Americans are currently using Emergency Rooms as de facto public health care, in enormous volume. Everyone involved agrees that this is both extremely costly and delivers low quality care (except in the true emergencies that the departments are designed for.) Unless we are going to repeal EMTALA (no politician would dare have that vote on their resume), we are stuck with Universal Health Care.
To be clear, we all are paying out the nose for this horrid form of Universal Care through cost shifting. Hospitals overcharge for virtually every service, in part to compensate for losses caring for the uninsured as required by EMTALA. The cost savings at standalone radiology and surgery centers comes mainly from cherry-picking the high revenue services and avoiding care for those without coverage. But this in turn forces hospitals to overcharge for their services even more. This cycle is at the center of our crisis as a whole, and absolutely affects even those of us with "good insurance."
We have to build a better safety net. Even we (proverbially individualistic and selfish) Americans won't stomach going completely bare. Next post is about what that might look like. The following is my personal framework, but if you're reading this, I welcome other's input before I write that entry.
1. A bare-bones public plan that all citizens pay in on a sliding scale, and covers everyone.
2. A private system of supplemental coverage and services.
Thursday, January 12, 2012
Free Medicine???
I mentioned in my last post that there is an assumption that health care is expensive. In order to challenge that assumption, I began to specifically list elements that are necessarily costly and those that might have wiggle room. Getting open heart surgery is going to be somewhat expensive no matter how lean the ship is run. But open heart surgeries aren't the care that's breaking the collective bank. It could be argued, however, that the cost of medication is one of the deal breakers.
When I was in residency, the community clinic nearest me stocked basic antibiotics and dispensed them under their sliding fee schedule. This meant that many patients got their medicine for free. Stock bottles of amoxicillin, Bactrim, tetracycline, and others sat in the med room and providers dispensed the medicine directly under some specific guidelines and policies. Though this still occurs, regulation and standardization makes this a little more difficult. Many free clinics, however, do have associated pharmacies that offer very inexpensive or free medication.
Walmart made a huge splash with their $4 medicine program, and so many pharmacies have followed suit that extremely low cost, old generics have become a norm. Schnuck's offers many of the same antibiotics my community clinic stocked for free. (The assumption being that they easily make up their cost when you buy a 20 ounce soda on the way out.) As a pinko hippy, I'm not a big fan of Walmart, but one has to wonder how much this move has fueled the decrease in national spending on prescription drugs.
http://www.phrma.org/catalyst/retail-prescription-drug-spending-hits-lowest-growth-rate-over-50-years
Other factors such the economy, increased regulation of pharmaceutical marketing to physicians, and the lack of new "blockbuster" drugs are major players in this slowdown. However, over several years of writing prescriptions in the $4 era, I have found myself saying "Yes patent drug X is better than cheap generic Y. It's been proven about 10% better." Out of pocket costs for typical branded drugs are $80-120 a month and even patients with good commercial insurance often have $25-50 copays. The math is not difficult.
The $4 drug plan began in 2006, and the economic downturn not long after. In any case, the state of the economy of prescription drugs is vastly different that in 2005 when I moved to this practice. However, the old version of "free medicine" still inhabits almost every doctor's office - samples. Samples are of course a method of advertising. The only medications sampled are newer, on-patent products and the idea is that a patient could get their first month of a drug and if it is well tolerated, they could get a prescription after that. However, at least half of the samples are used to supply patients who would not have been able to afford their medication otherwise. The problem comes when there are not enough samples and a patient then must try to fill a significantly more expensive medication. And, by force of habit, a physician tends to use familiar medications. If a sample is readily available, it is more likely to be written on a prescription. Even today, some providers routinely prescribe patented medications that are at best equivalent to cheap generics.
There are some patented drugs that have no generic substitute. Different pharmacies charge wildly different prices for generic medications. And though generics are quite reliable, different companies' products do not always interchange seamlessly. This is notoriously true for thyroid replacement. Generics are not perfect. But for almost every single common condition, there are options.
No one should go untreated because of drug cost in 2012. Prescription assistance programs through the drug companies themselves provide enormous quantities of medication to low-income patients. Many Community Clinics are supported by a 340b grant which greatly discounts medications for their patients.
The problem is not solved by any means. In a recent trip to Walgreen's I was given three different prices for a course of amoxicillin ranging from $30 to $11. This is a medication that is on almost every $4 list and is probably the most common free antibiotic. You still have to be a very savvy consumer to maximize the system. There is still a LOT of profiteering in the pharmaceutical industry. I hope to get a chance to explore how things could be improved in future blogs.
When I was in residency, the community clinic nearest me stocked basic antibiotics and dispensed them under their sliding fee schedule. This meant that many patients got their medicine for free. Stock bottles of amoxicillin, Bactrim, tetracycline, and others sat in the med room and providers dispensed the medicine directly under some specific guidelines and policies. Though this still occurs, regulation and standardization makes this a little more difficult. Many free clinics, however, do have associated pharmacies that offer very inexpensive or free medication.
Walmart made a huge splash with their $4 medicine program, and so many pharmacies have followed suit that extremely low cost, old generics have become a norm. Schnuck's offers many of the same antibiotics my community clinic stocked for free. (The assumption being that they easily make up their cost when you buy a 20 ounce soda on the way out.) As a pinko hippy, I'm not a big fan of Walmart, but one has to wonder how much this move has fueled the decrease in national spending on prescription drugs.
http://www.phrma.org/catalyst/retail-prescription-drug-spending-hits-lowest-growth-rate-over-50-years
Other factors such the economy, increased regulation of pharmaceutical marketing to physicians, and the lack of new "blockbuster" drugs are major players in this slowdown. However, over several years of writing prescriptions in the $4 era, I have found myself saying "Yes patent drug X is better than cheap generic Y. It's been proven about 10% better." Out of pocket costs for typical branded drugs are $80-120 a month and even patients with good commercial insurance often have $25-50 copays. The math is not difficult.
The $4 drug plan began in 2006, and the economic downturn not long after. In any case, the state of the economy of prescription drugs is vastly different that in 2005 when I moved to this practice. However, the old version of "free medicine" still inhabits almost every doctor's office - samples. Samples are of course a method of advertising. The only medications sampled are newer, on-patent products and the idea is that a patient could get their first month of a drug and if it is well tolerated, they could get a prescription after that. However, at least half of the samples are used to supply patients who would not have been able to afford their medication otherwise. The problem comes when there are not enough samples and a patient then must try to fill a significantly more expensive medication. And, by force of habit, a physician tends to use familiar medications. If a sample is readily available, it is more likely to be written on a prescription. Even today, some providers routinely prescribe patented medications that are at best equivalent to cheap generics.
There are some patented drugs that have no generic substitute. Different pharmacies charge wildly different prices for generic medications. And though generics are quite reliable, different companies' products do not always interchange seamlessly. This is notoriously true for thyroid replacement. Generics are not perfect. But for almost every single common condition, there are options.
No one should go untreated because of drug cost in 2012. Prescription assistance programs through the drug companies themselves provide enormous quantities of medication to low-income patients. Many Community Clinics are supported by a 340b grant which greatly discounts medications for their patients.
The problem is not solved by any means. In a recent trip to Walgreen's I was given three different prices for a course of amoxicillin ranging from $30 to $11. This is a medication that is on almost every $4 list and is probably the most common free antibiotic. You still have to be a very savvy consumer to maximize the system. There is still a LOT of profiteering in the pharmaceutical industry. I hope to get a chance to explore how things could be improved in future blogs.
Wednesday, January 11, 2012
Medicine and Money, Part 1 of Many
When the term "Health Care Reform" is mentioned, the first issue that comes to most minds is cost. The most common reasons people say "Our health care system is broken" are economic. Insurance companies, socialized medicine, tort reform, formularies...the arguments really are all too often about the exchange of money.
There is an assumption that health care is expensive, so expensive that no one is expected to be able to pay out of pocket at the time of specific need. Truly, very few have $100,000 laying around in the event of a serious automobile accident requiring surgery, hospitalization, and weeks of rehab. Most don't have $15,000 laying around if they need their gallbladder out. The assumption continues that we MUST pool resources so that the money is there when the need arises.
Wait a second, isn't that socialism? Of course it is, depending on your definition. The only question that's really being debated is who gets to collect and distribute the money (which for fun I'm going to refer to as the "pot of gold"). Private organizations (still commonly grouped under the label "insurance companies") perform that function for many of us, and their dynamics are different than when the government adminsters the pool. But regardless of who takes care of the books, the reason any of us are willing to put our gold into the pot is that we expect to be able to get medical care when we need it, especially if something really big and scary happens.
But there's a problem. Pots of gold are tricky things. It is virtually impossible to look at a pot of gold and avoid thinking "Wow what I could do with that!" Pots of gold tend to make people do things they wouldn't otherwise do, ranging from bending the truth a little about why some of that gold belongs in my pocket to outright thievery (or worse). The bigger the pot of gold, the further people are willing to go.
The economy of modern medicine in America is one of the biggest pots of gold in history. It has attracted thieves and scavengers. Good people tell lies large and small to make sure their part of the gold is secure. In a classic example, the hospital charges us $5 for a Tylenol, and tells us it's to pay for the uninsured patient in the ICU. We grumble but accept this, another de facto socialization of medical economics. Different patients are charged radically different amounts for the same service based on who is managing the pool of money to which they contribute. Many medical providers won't release their prices, because the amount of money changing hands is so fluid that the word "price" is meaningless. Insurers try to trick patients into paying bills they don't owe, and try to avoid paying what they've contractually agreed to pay. Medical providers in turn further distort "prices" to try to compensate.
This is not a free market. This is not an open economy finding the most efficient way to distribute resources. This is people telling each other lie after lie after lie as they shuffle around shares of the pot of gold. And the greatest lie is the one that we all tell ourselves so often. That the pot of gold is infinite, that in MY case (whether it's a lawsuit, an expensive medication, my company's business practice, my personal salary, or one more test on a dying loved one), I can ignore the system as a whole.
This may seem to be belaboring the obvious, but I think getting to the basics is essential if we're going to modify the leviathan social organism that is American medicine.
More thinking to do...
There is an assumption that health care is expensive, so expensive that no one is expected to be able to pay out of pocket at the time of specific need. Truly, very few have $100,000 laying around in the event of a serious automobile accident requiring surgery, hospitalization, and weeks of rehab. Most don't have $15,000 laying around if they need their gallbladder out. The assumption continues that we MUST pool resources so that the money is there when the need arises.
Wait a second, isn't that socialism? Of course it is, depending on your definition. The only question that's really being debated is who gets to collect and distribute the money (which for fun I'm going to refer to as the "pot of gold"). Private organizations (still commonly grouped under the label "insurance companies") perform that function for many of us, and their dynamics are different than when the government adminsters the pool. But regardless of who takes care of the books, the reason any of us are willing to put our gold into the pot is that we expect to be able to get medical care when we need it, especially if something really big and scary happens.
But there's a problem. Pots of gold are tricky things. It is virtually impossible to look at a pot of gold and avoid thinking "Wow what I could do with that!" Pots of gold tend to make people do things they wouldn't otherwise do, ranging from bending the truth a little about why some of that gold belongs in my pocket to outright thievery (or worse). The bigger the pot of gold, the further people are willing to go.
The economy of modern medicine in America is one of the biggest pots of gold in history. It has attracted thieves and scavengers. Good people tell lies large and small to make sure their part of the gold is secure. In a classic example, the hospital charges us $5 for a Tylenol, and tells us it's to pay for the uninsured patient in the ICU. We grumble but accept this, another de facto socialization of medical economics. Different patients are charged radically different amounts for the same service based on who is managing the pool of money to which they contribute. Many medical providers won't release their prices, because the amount of money changing hands is so fluid that the word "price" is meaningless. Insurers try to trick patients into paying bills they don't owe, and try to avoid paying what they've contractually agreed to pay. Medical providers in turn further distort "prices" to try to compensate.
This is not a free market. This is not an open economy finding the most efficient way to distribute resources. This is people telling each other lie after lie after lie as they shuffle around shares of the pot of gold. And the greatest lie is the one that we all tell ourselves so often. That the pot of gold is infinite, that in MY case (whether it's a lawsuit, an expensive medication, my company's business practice, my personal salary, or one more test on a dying loved one), I can ignore the system as a whole.
This may seem to be belaboring the obvious, but I think getting to the basics is essential if we're going to modify the leviathan social organism that is American medicine.
More thinking to do...
Monday, January 9, 2012
One Crazy Afternoon
In affirmation of the Universe's sense of humor, the first patient into my grand plan to create a brighter medical experience promptly passed out while trying to leave her appointment. She was taken to the ER in a stretcher and I can safely say that neither she nor myself had a spiritually fulfilling encounter.
There are many issues that could be addressed related to this case including the cost that is going to be charged the system for this (rough guess $15 thousand dollars by the time the patient is observed overnight and released) or how we deal with our increasing numbers of very ill patients that modern medicine has allowed to remain living in the community (a great success to be sure but a management nightmare).
Instead, I'd like to keep to topic and explore the visits for the rest of the afternoon. I saw a fairly typical mix of respiratory infections, medical follow ups, new patients seeing me because of insurance changes, and mental health. Though my "project" spurred me a bit to try to make the best of these visits, I certainly didn't feel great satisfaction at any point. One patient was, in fact, quite happy because we had finally found the right medication after months or even years of never quite hitting the mark. But there were none of the "Aha" moments that remind you why you went into medicine.
I felt that I had done my job adequately or even well in every case, and I think every patient went away at least satisfied. But my sense of presence and intensity of attention were not going to be at their peak. Which leads me to the simple idea that the key to the best encounters follow rules that have little to do with exam rooms, payers, personnel, or the tea party. The best encounters are simply when people give their real attention and their true energy in those moments to the relationship.
I feel these moments most often early in the process of treating mental health issues, but that's my personal interest, my niche in my local healthcare system. It occurs to me that optimizing health care may be, in part, the process of simply allowing these genuinely present human interactions to take place. And part of my job is to figure out how I can bring presence and not allow my frustrations with medicine as a whole ruin the one thing I truly do have some power over.
But given the fact that this is only the third patient in six years that I've had to call EMS for, I'll give myself a little break. A few points to ponder for the evening.
There are many issues that could be addressed related to this case including the cost that is going to be charged the system for this (rough guess $15 thousand dollars by the time the patient is observed overnight and released) or how we deal with our increasing numbers of very ill patients that modern medicine has allowed to remain living in the community (a great success to be sure but a management nightmare).
Instead, I'd like to keep to topic and explore the visits for the rest of the afternoon. I saw a fairly typical mix of respiratory infections, medical follow ups, new patients seeing me because of insurance changes, and mental health. Though my "project" spurred me a bit to try to make the best of these visits, I certainly didn't feel great satisfaction at any point. One patient was, in fact, quite happy because we had finally found the right medication after months or even years of never quite hitting the mark. But there were none of the "Aha" moments that remind you why you went into medicine.
I felt that I had done my job adequately or even well in every case, and I think every patient went away at least satisfied. But my sense of presence and intensity of attention were not going to be at their peak. Which leads me to the simple idea that the key to the best encounters follow rules that have little to do with exam rooms, payers, personnel, or the tea party. The best encounters are simply when people give their real attention and their true energy in those moments to the relationship.
I feel these moments most often early in the process of treating mental health issues, but that's my personal interest, my niche in my local healthcare system. It occurs to me that optimizing health care may be, in part, the process of simply allowing these genuinely present human interactions to take place. And part of my job is to figure out how I can bring presence and not allow my frustrations with medicine as a whole ruin the one thing I truly do have some power over.
But given the fact that this is only the third patient in six years that I've had to call EMS for, I'll give myself a little break. A few points to ponder for the evening.
Brainstorming Health Care Change
I have done more than my share of complaining about how broken our health care system is, and have made the claim that health care reform has been my personal #1 issue when I vote. I've bemoaned the failure of the Clinton Administration's attempt to reform our system, and done my share of criticizing the 2010 Affordable Health Care Act. At the same time, I've also been vocal about my relief that we're at least doing SOMETHING.
All of that is rather vanilla opinion that probably isn't detailed enough for someone who takes comfort in the fact that I work in a Community Health Center. As I've been reading about efforts within the environmental movement to create change from the ground up, I've decided to explore, at minimum, what I really think health care should look like. At the same time, I want to welcome comments from friends and colleagues so that my views can grow. The hope is that I can form a vision for an intentional practice in the future, and perhaps all who enter here might help each other develop a more nuanced conception of our mutual problem.
So I start with some really basic observations from the exam room.
1. Patient priorities and provider priorites are quite different. Patients seek out care for pain and illness, hoping to be relieved of suffering. Providers / doctors want to diagnose and treat. Obviously there is a lot of overlap, but it is extremely common for my time in the exam room to involve me wanting to optimize blood pressure and blood sugars while the patient wants their chronic knee pain fixed.
2. Neither one of us really wants to deal with the money. Patients rarely know the details of their coverage, and I also avoid learning specific formularies, copay structures, etc. Always looming is the expectation that care is payer blind but in reality almost every single patient encounter is affected by cost.
3. Most everyone feels overwhelmed and powerless. The pressure to see more patients with less cost leaves both provider and patient unhappy. Patients know that their access to most modern healthcare technology must go through a trained gatekeeper. I hate being a gatekeeper. I would rather be an advisor and a guide.
So I'm sitting here staring at this list, just another bit of complaining. The inspiration for this blog was reading a book (NO IMPACT MAN) where a guy who was really upset about a problem just jumped off to try to make his part better.
What can I do today? Now?
After staring at the screen for 15 minutes, I realized that what I want most of all is to have meaningful encounters. Where I walk out and the patient walks out feeling something was accomplished. Time well spent.
So this afternoon, I am going to ask myself for each visit. Do I feel satisfied with that encounter? Do I think the patient did? Why?
We'll see where it leads.
All of that is rather vanilla opinion that probably isn't detailed enough for someone who takes comfort in the fact that I work in a Community Health Center. As I've been reading about efforts within the environmental movement to create change from the ground up, I've decided to explore, at minimum, what I really think health care should look like. At the same time, I want to welcome comments from friends and colleagues so that my views can grow. The hope is that I can form a vision for an intentional practice in the future, and perhaps all who enter here might help each other develop a more nuanced conception of our mutual problem.
So I start with some really basic observations from the exam room.
1. Patient priorities and provider priorites are quite different. Patients seek out care for pain and illness, hoping to be relieved of suffering. Providers / doctors want to diagnose and treat. Obviously there is a lot of overlap, but it is extremely common for my time in the exam room to involve me wanting to optimize blood pressure and blood sugars while the patient wants their chronic knee pain fixed.
2. Neither one of us really wants to deal with the money. Patients rarely know the details of their coverage, and I also avoid learning specific formularies, copay structures, etc. Always looming is the expectation that care is payer blind but in reality almost every single patient encounter is affected by cost.
3. Most everyone feels overwhelmed and powerless. The pressure to see more patients with less cost leaves both provider and patient unhappy. Patients know that their access to most modern healthcare technology must go through a trained gatekeeper. I hate being a gatekeeper. I would rather be an advisor and a guide.
So I'm sitting here staring at this list, just another bit of complaining. The inspiration for this blog was reading a book (NO IMPACT MAN) where a guy who was really upset about a problem just jumped off to try to make his part better.
What can I do today? Now?
After staring at the screen for 15 minutes, I realized that what I want most of all is to have meaningful encounters. Where I walk out and the patient walks out feeling something was accomplished. Time well spent.
So this afternoon, I am going to ask myself for each visit. Do I feel satisfied with that encounter? Do I think the patient did? Why?
We'll see where it leads.
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