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Worth It

I saw the note on the patient's chart before I opened the door: "patient is upset that he had to come in."

I opened the door and was greeted by a gentleman with his arms crossed tightly across his chest and a stern expression.  I barely recognized him, having only seen him a handful of times over the past few years.  Scrawled on the patient history sheet  in the space for the reason for his visits were the words: "Because I was forced to come in."

By stomach churned.  I opened his chart and looked at his problem list, which included high blood pressure and high cholesterol - both treated with medications.  He was last in my office in November...of 2008.  I blinked, looked up at his scowling face, and frowned back.  "You haven't been in the office for over eighteen months.  It was really time for you to come in," I said, trying to remain calm as I spoke.

He sat for a moment, then responded with very little emotion: "I am doing fine.  You could have just called in an order for labs and called in my prescriptions.  I don't know why I had to be seen."

"You have hypertension and high cholesterol.  These are serious medical problems, and if I am going to put my name on a prescription for you, I have to make sure everything is OK," I responded, trying to hide my growing anger.  "I am not a vending machine that you can call to get drugs."

"I'll come in if I am sick, but I am not sick right now."

"My job is to make sure you don't get sick in the first place!" I said, my volume rising slightly.  "I don't bring you in because I need the business; I've got plenty of patients to fill my schedule.  These medications are not risk-free.  Besides, how do I know if your blood pressure is OK?"

"I check my own blood pressure at home and it has been good.  I can't afford to come in to the doctor so much.  I have a high-deductible plan.  I had a stress test and a colonoscopy last year, and that's enough spending for me," he responded, his pitch and volume rising with mine.

"I have to say that I find this personally insulting,"  I threw back.  "You don't think I am worth paying to see.  You just want me to give you your medications, take the risk of adverse reactions, and basically work for free?"

"That's not what I said!"

"It is exactly what you said!" I said, not hiding my frustration.  "You want me to prescribe a medication, trust you for your blood pressure, interpret the lab results, and take the legal risk for your prescriptions and not get paid a dime for it!  You are asking me to give you bad care because you don't think I am worth paying.  I don't do that. I won't give you bad care.  If you wan't bad care, feel free to find a doctor who will give it to you; if you are going to come to this office I will make you come in on a regular basis.  If you don't think I am worth it, then I am sorry."

He sat quietly for a moment, and I took a deep breath.  "Don't you have a health savings account?" I asked, trying to calm my voice again.  "Most people with high-deductible plans have HSA's."

"Yes, we have an HSA, but we are trying to hold on to that money."

"An HSA is an insurance plan!" I said, not hiding my incredulity.  "This is what you've been saving that money for!  I want to keep you out of the hospital, keep you from the emergency room, and keep you from spending all your money for a hospital stay.  One overnight stay in the hospital will cost you more than 100 visits to my office."

He again sat quietly for a moment, and I directed him up on the exam table.  We talked about his medications and potential side effects.  I pointed out that there are cheaper alternatives for his blood pressure pill that have fewer side effects.  I discussed cardiac screening tests and explained the pros and cons of prostate cancer screening.

I changed his prescription to something cheap enough to recoup the cost of my visit in two months.  As the visit went on, his eye contact grew less and less.  My point was made.  I was giving him something the Internet or a "doc hotline" couldn't give; I saved him money, educated him, and improved his life.

When I had finished with the visit, I handed him the clipboard.  "I'll see you in six months."

He didn't respond, but I could see that he got far more out of the visit than he expected.  I am the one doctor out there whose main goal is to keep him away from the hospital and away from having expensive tests.  I often tell my patients that my goal is to get all of my patients very old and to see them as infrequently as possible.

But I am not a vending machine for prescriptions.  I won't work for free.  I won't take risk without expecting to be paid for it.

I hope he comes back.

I hope he realizes I am worth it.




Name of Drama:  21 Protagonist:  Dr. Rob and a cast of thousands of physicians (Kiefer Sutherland wouldn't work for such small payment)

Villain:  Evil SGR conspiracy to cut Medicare by 21% across the board.

Victim: The elderly population depending on Medicare for payment of their care

Plot:  A follow-up of the popular drama "Lost" where members of congress were stranded in Washington DC with the task of reforming healthcare without any contact or communication from doctors and patients.  This new drama "21" tells the tragic tale of an industry under siege and a population facing possible disaster.

Already stretched to the limit by the paltry reimbursement from Medicare for primary care office-visits, Dr. Rob and his band of physicians is hit by the evil conspiracy of SGR.  SGR is a secret society whose goal is to harm the elderly people in the country by driving away all people willing to give them care.  The congress, tired out from haggling over the health care reform bill, allows evil SGR to exert its power in the name of "fiscal responsibility."

Within a short period of time around the (appropriately) April 1st reimbursement drop, thousands of physicians stop accepting new Medicare patients and consider dropping the plan altogether.  Medicare patients are left to fend for their own care without anywhere to go to get it.  Dr. Rob runs down the hall yelling something on every episode - solely for dramatic effect - although he does uncover an crop-dusting cartel that plans on world domination by dropping fliers for a cut-rate insurance scam.

Will congress see the ruin of Medicare before it's too late?  Will any primary care physicians be able to afford to care for Medicare patients?  Will dentists and veterinarians be called to emergency duty with the sudden loss of primary care?  Will Oprah's llama adoption ever go through?

Tune in and find out.



Stressed Out System

I saw a patient today and looked back at a previous note, which said the following: "stressed out due to insurance."  It didn't surprise me, and I didn't find it funny; I see a lot of this.  Too much. This kind of thing could be written on a lot of patients' charts.  I suspect the percentage of patients who are "stressed out due to insurance" is fairly high. My very next patient started was a gentleman who has fairly good insurance who I had not seen for a long time.  He was not taking his medications as directed, and when asked why he had not come in recently he replied, "I can't afford to see you, doc.  You're expensive."

Expensive?  A $20 copay is expensive?  Yes, to people who are on multiple medications, seeing multiple doctors, struggling with work, and perhaps not managing their money well, $20 can be a barrier to care.  I may complain that the patients have cable TV, smoke, or eat at Taco Bell, but adding a regular $20 charge to an already large medical bill of $100, $200/month, or more is more than some people can stomach.  I see  a lot of this too.

Finally, I saw a patient who told me about a prescription she had filled at one pharmacy for $6.  She went to another pharmacy (for reasons of convenience) to get the medication filled, and the charge was $108.  I could see the frustration and anger in her eyes.  "How do I know I am not getting the shaft on other medications?" she lamented.  I told her that I see a lot of this.

Then I started considering how many doctors, nurses, and hospital administrators are "stressed out due to insurance," and I laughed.  I think the number of those not stressed out would be far easier to count.  In this blog I have recounted the overall cost the insurance situation takes from my own practice, and my own psyche.  I can't do it justice in a single post, it takes a huge toll on those of us in it.  The cost is high.

So what is the overall cost of a bad system?  Sure, the system itself uses money poorly and dumps buckets of money on things that have no impact on the health of patients.  Sure the system encourages doctors to not communicate, not spend time with patients, and to spend more time with the notes than with the patient.  But what is the toll of this toll?  What is the toll that simply having an insane system that demands huge sums of cash, yet does not give back a product worthy of that cost?  What is the toll of people suspicious that they are being gouged at the pharmacy, hospital, or doctor's office?  What is the cost of having a healthcare workforce that goes home more consumed by frustration about the system than by the fact that people are sick and suffering?

Our system is very sick, and the fact that it is so sick makes me sick.  It makes a lot of us sick.

I see a lot of that.



Good Conscience is Bad Business

I am going to state something that is completely obvious to most primary care physicians:  I do not accept Medicare and Medicaid patients because it is good business, I accept them despite the fact that it is bad business. In truth, I could make that statement about insurance as a whole; my life would be easier and my income would be less precarious if I did not accept any insurance.  If I did, I would charge a standard amount per visit based on time spent and require payment at the time of that visit.  This is totally obvious to me, and I suspect to most primary care physicians.  A huge part of our overhead comes from the fact that we are dealing with insurance.  A huge part of our headache and hassle comes from the fact that we are dealing with insurance.

If I chose to post my charges up front and expected payment at the time of the visit, the impact to the business would be huge.  As  it stands, the percentage of my collections that goes to overhead is between 50 and 60% (depending on the month).  A huge amount of that overhead is due to the need to hire a large billing staff to deal with the complexity of coding, billing, and documenting.  If I dropped insurance and charged a fixed amount, I could:

  1. Cut my billing staff nearly to zero (someone would still have to do bookkeeping).
  2. Increase my payment per visit, which would allow me to see less patients per day.
  3. Document for the sake of patient care, and not for the sake of getting paid.
  4. Add extra services like email access and house calls without worrying about how I would get paid.

In short, I could make my life better, my hassle less, and improve the quality of the care I offer.

So why just single out Medicare and Medicaid?  Dropping insurance would force all of my M/M patients to find another doctor, while my patients with insurance could still choose to see me.  There are several reasons why this is possible for insured patients:

  • Insured patients generally have the option of filing for their own insurance (there are some that still don't allow this, but that number is dwindling with the decrease of HMO's)
  • Insured patients could choose to just pay me cash if they choose

Can't Medicare/Medicaid patients do this?  No, for several reasons:

  • If a doctor does not accept M/M, the government will not pay anything for the visit regardless of who files.
  • If the doctor does accept M/M, they are required to accept that payment and cannot charge anything outside of that (aside from the 20% not covered).  So if I charge a M/M $50 cash for a visit and am a signed up to accept M/M, I am committing fraud.
  • If I drop M/M, I cannot sign up for it again for 3 years, so the impact of that move is too large to consider at this time.

So why in the world do I accept M/M still?  Why would I continue to make my life so difficult?  Two words: duty and calling.  I view my seeing M/M patients as a social responsibility (especially Medicare).  These people need to be seen and they deserve good care, and despite the hassle and drain on income they cause, I make a reasonable income.  So far.

Plus, I just like to take care of the elderly and the poor.  My personal reasons for going into medicine included both a desire to have a good job and the calling to care for people in need.  If I dropped M/M I would reject the calling for personal gain, which is something I can't do in good conscience at this time.

The fact that the only thing keeping me accepting M/M is my conscience (and tolerance of pain) gives a really clear explanation as to why M/M are failing in the realm of primary care.  The government is not paying enough to make a good business case to accept M/M; instead it is relying on the consciences of primary care physicians like me who are willing to put up with the huge hassle of the system.  I am personally willing to continue on this course as long as (it doesn't get too much worse) but I have complete sympathy for PCP's who drop insurance and no longer see M/M patients.

One of the biggest costs to our system is the high proportion of specialists to PCP's.  PCP's keep down cost, as their success is measured by keeping people healthy, away from specialists, and out of the hospital.  The system is just holding on with the PCP's we have; decreasing that number would be devastating and perhaps fatal to the system.  It's a very bad sign when the best business model for PCP's is to do something that, if done by all PCP's, would wreck the system.  Yet even physicians like myself, who have a strong sense of duty and social responsibility, wonder how long we can afford to take M/M.

I am sure some are thinking: Poor Doctors!  They have to earn less money!  They have to actually have a conscience!  What a horrible thing! To that I answer with the fact that I have chosen to earn less money, increase my hassle, and live by my conscience.  At this time, most PCP's accepting M/M are doing the same.  But setting up a system that requires the choice between conscience and sanity, between doing the right thing and self-care, is foolish.  Pushing down M/M payments for PCP's will make a bad situation worse.

That's bad politics, bad medicine, and bad business.

Consider yourself warned, Washington.



Coming Short with Thinking

I am mad at congress.

I don't care if they are Democrats or Republicans, I am sick of healthcare being treated as a political football.  How much more of a crisis do we need before we actually start working on a solution?  Why does each party have to sit on its side of the aisle shooting spitballs at the other?  Each side has its pet issues that are tied to contributors, supporters, and lobbyists.  Each side will work to see the other side fail even if the other side is right.  Each side seems unable to do anything unless there is political value in it.  Power is more important than service, and power is a short-term project.

The real problem is that congress is thinking of short-term political gain while sabotaging the long-term.  It's like the publicly traded company that works to maximize quarterly profits even if it damages the corporation in the long run.  Our society thinks in the short not in the long, and our congressmen are doing so in a way that harms all of us.

I thought of this while I was in the shower this morning.  I am not sure if it is the shampoo, but I have thoughts about blog posts while I'm in the shower.  I was getting filled with righteous rage about the stupidity of congress and how they mimic corporate America in short-sightedness.

Then I realized something: I do the same thing in my personal life.  I am trying to eat better and exercise, but that brownie in the break room looks awfully tempting.  A little indulgence now won't hurt in the long-run, will it?  I start playing that damned Bejeweled game on Facebook instead of working around the house.  It's only one night, and I am stressed-out about stuff.

Perhaps it's the soap that gets me thinking this way.

Living my life making decisions based on my immediate feelings is the same stupidity that infects congress.  I indulge for personal gain in the short-term and let tomorrow's crisis build.  I have had people younger than me have heart attacks and die; do I really want my last night on earth be spent playing Bejeweled?  Worse yet, if I survive and keep acting in this way, do I really want the measure of my life be how many brownies I eat or what my high score is on a game?  It's not that I don't realize I should spend my days better; it's just human nature that thinks in the now in ways that harm the future.

Then I thought about my patients: they do the same thing.  My patients who are overweight, smokers, alcoholics, non-compliant, in bad relationships, neglecting their children, or hating others because of superficial differences - they are not all that different from me.  They are not different from congress.  They are living in the now because humans do that.  Humans overcharge their credit cards to the point that they can't even afford the monthly payments.  Humans buy cars with money they don't have just to get the warm feeling of having a new toy, and the joy of making others jealous.

It doesn't justify stupidity, but it does explain it.  I feel righteous anger toward congress because I see the result of their inaction.  I see the harm caused to people by a dysfunctional system.  My paycheck is affected by it.  Congress can't resist the brownies; they can't stop playing Bejeweled.  Congress can't stop smoking, or stop spending money on credit cards.

So how do we fight this battle that is all too human?  How do we get congress to act in a way that's best for us, not them?  How do we get ourselves to spend time with the kids, not the blog?  How do I get my patients with heart disease to stop smoking?

I don't know.  I had to get out of the shower.

Photo Credit



My Heart Flu Away

Dear Influenza Vaccine: I am sorry to be so formal, but using your pet name, "flu shot", doesn't seem appropriate in a letter like this.  I am also sorry to be writing this letter; I don't want you to be hurt and I don't want others to think bad of you.

I just don't love you any more and want out of our relationship.

Don't get me wrong; I still think you save lives.  You are strong, noble, and deserving of appreciation.  You give to my patients what I seek to give them: a longer life with less sickness, and you do so without much cost.  I will never think badly of you in that way.  I even want to continue meeting with you every year.  I don't want to lose touch.

But things have gotten hard for me.  You give so much to others, yet you make my life so very hard.  I never know how many people will want you, and yet I have to order you six months or more in advance.  I get you for a time, and then when I am getting comfortable with you here, you leave.  I get promises that you will come back, but those promises have left me waiting so many times that they run hollow.  My patients have grown to appreciate you, yet you tease them every year by running out, being delayed, or simply not being here for mysterious reasons nobody will explain.  They blame me for your behavior, and that is so unfair.  They think I am keeping them from you, but it just isn't so.

I am afraid to ask about this, but why is it that you spend so much more time at Wal-Mart and Walgreens?  It seems that you don't tease them like you do me.  It seems that you are there whenever they need you, but for me you play your game of hide-and-seek.  Do you love them more then you love me?  Or is it that they lure you with their riches and power?  I can't offer you that.

Then there is the way you steal from me.  Every year I pay so you can come back to be with me, and every year I end up on the short end of things.  I give of myself, yet you don't give back to me - the one who stood up for you when things were bad.

It's just not worth it.  I just cant take the games, your divided heart, and the cost I pay every year to have you with me.  I want you to be happy and for people to love you, but I just don't think this is not working out between us.

Where would you stay if not with me?  You will still have the retail stores, but I wonder if you should stay with my Uncle Sam.  He's the one who set us up in the first place, and he's the one who fixes you up every year.  He's the one with the responsibility for the people you serve and the public interest is his more than it is mine.

Whatever the case is, I need to find a way to get out of this relationship.  It hurts me every year, and I am tired of bearing the pain.

Please understand that I wish you only the best.


Dr. Rob



Breast Cancer and Emotions

Breast cancer makes me quite emotional. My mother and two of my sisters have had breast cancer; all were picked up with mammograms.  A good friend of ours was diagnosed in her forties with aggressive breast cancer through mammography.  She is currently doing well.

I don't like breast cancer and am definitely against women dying from it.

This is my backdrop when I consider the USPTF's latest recommendations:

  • The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation.
  • The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. Grade: B recommendation.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Statement.
  • The USPSTF recommends against teaching breast self-examination (BSE). Grade: D recommendation.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Grade: I Statement.

This has made the general public quite emotional.

There has been a huge public backlash.  People don't trust these findings and are willing to talk about it.  Why in the world would they recommend against teaching self-breast exam?  Is this the Obama administration's ploy to cut cost?  Are women's health concerns being pushed aside for the sake of saving money?

Now congress is getting involved. There are going to be congressional hearings about the issue of how breast cancer screening is best done.

Why has this sparked so much emotion?  Nobody got worked up with the recommendations about car seats.  As emotional an issue as immunizations is to many, recommendations in that area do not spark congressional hearings, front page articles, and public emotion like these breast cancer recommendations.

There are several things that charge this issue beyond that of rational debate:

  1. It is happening in the midst of reform discussions.  Anything that recommends less care is held suspect, as the timing implies that this is a politically motivated recommendation.
  2. It deals with a disease that brings fear in most of us, pulling out the reassurance that it can be prevented.  People want to believe that science can keep them from harm and this makes us feel more vulnerable again.
  3. It contradicts the previous recommendations that moved from simple science to public crusade.  Every woman who did not get mammograms or do self-breast exams were made to feel guilty about it.  Medical students and residents were scolded by attendings if they did not address this issue.
  4. It is a "women's issue" that makes some feel like women's needs are being set aside.

To everyone else, this is a political, social, and scientific discussion.  The debate can rage in the halls of congress, on TV talk shows, and over the blogosphere.  But at the end of the day, I am the one who has to face the patient and discuss the reality of cancer screening.  All of this talk and debate is about what I do for a living.  I am at the eye of this storm, despite what grandstanding congressmen make, what accusations Obama-haters fling, or what eye-rolling scientific purists say.

That makes me quite emotional.

My job is being taken over by congressmen.  They will decide what is appropriate for me to order, and not doing so will go against the standard of care.  Medical science is being torn away from what's best for people and is becoming fodder for stump speeches, talk shows, and attacks on political opponents.  Discussing mammograms in the exam room no longer centers around what is best or what has the best evidence, it centers on politics.

Please let me be a doctor.  Please let me get to know the patient, read the authorities I trust, and make the best decisions for that patient.  Stay away from this, politicians!  You are bad at making political decisions, so why should you be trusted in medical decisions?  Don't say you do this in the public interest when it clearly involves what's best for your political career.  I don't like being a pawn.

Unfortunately, there is little chance of that.  If a recommendation by the USPTF causes this kind of brouhaha, do you think good reform can really happen?  I doubt it.

And that makes me quite emotional.

This post isn't about the content of those recommendations.  I have read both sides of the issue and see rationale both ways.  I would rather not debate the issue itself (it caused an argument at home this morning already), as I understand how people's emotions are high as well.  I am just frightened of a world in which science needs to be ratified by congress.  I don't like it when Oprah has an influence on how I do my job.  I don't like the USPTF to be accused of being a covert wing of the Democratic party.

My job is hard enough.  My decisions are hard enough.  My days are hard enough.  Why can't I just be a doctor?



Defining Terms

I have a confession: I am cynical about Washington's efforts to pass good healthcare reform. Sorry for those of you who I just shocked; would those standing next to them please administer CPR?  I know most of you trust our government to do what's best.  Sorry to burst that bubble.

The reason I am cynical is that I think the real problem has nothing to do with healthcare; it has to do with the way our government runs.  Here's why:  let's wildly imagine that one party came up with a plan that would actually fix the problem.  This plan would:

  1. Ensure that all Americans have coverage.
  2. Improve the quality of care, and set in place means to continue improving quality.
  3. Fairly reimburse medical professionals for what they do.
  4. Eliminate waste.
  5. Save money.

And let's say it did all this without pandering to special interests with deep pockets.

What would be the politically expedient thing to do for members of the other party?   They should oppose this plan with every ounce of their strength.   Politics is all about power, and if one party solved the healthcare problem they would be lauded as saviors.  They would have enormous political capital and would gain much more control of the government.  That wouldn't be good for the opposition.

So here's what the opposing party should do if they are thinking politically:

  1. Misrepresent this plan to the public as something that would result in disaster.
  2. Run commercials that would scare people.
  3. Get special interest groups to harass and threaten those who support this bill.  Make it so supporting this good bill would be an end to their political career.
  4. Try to influence members of the other party to vote against their colleagues in exchange for more power.

Politically, this would be the best thing to do.  It would also be the worst thing for our country.  It happens with regularity.

The reason this happens because nearly all of the members of congress are constantly campaigning.  They are constantly positioning themselves to get reelected, and this requires that they stay at or near the center of their own party.  If they break ranks and side with the other party, they stand to lose in the next primary election.  If the oppose the special interests with lots of money, they stand to have people spending that money to make sure they don't get reelected.

The system encourages partisans and punishes those who go by conscience or work for compromise.  The system dooms us to legislation aimed at maintenance of power.  The system guarantees that the better the legislation put forth by one party, the more the other will misrepresent and smear it.

Just like the headache isn't the main problem when a person ruptures an aneurism, the outward flaws of our government are caused by a much deeper problem: our legislators are far too vulnerable to abandon the greater good for the sake of political power.  To seek good is to give up power.  That dooms us to mediocre results at best.

There is one thing that would help undo this problem: term limits for members of congress.  Limiting senators to 2 terms, and members of the house to 3 would rid us of career politicians who are totally out of touch with the country they govern.

What's the problem with term limits?  It will take an act of congress to make it happen.

Unless the people force the issue.



Say "Yes" to Drugs

Dear Mr. Obama and all of you congress folks: I know you have been arguing about how to fix our system (and it really does need fixing).  I know there is not much you can all agree on.  I know it wasn't all that much fun to face those yelling people at the town hall meetings.  The press hasn't been nice, and the polls aren't good either.  You guys are having a rough go of it.

So I am going to do you a big favor.

What you need right now are some quick wins - some things you can do that will make people happy quickly, and things that can be done without much cost.  This is low-hanging fruit that can be picked without a high ladder; it is fruit that will sweeten things and make swallowing the more bitter pills a little easier.  Here is what you need to do first:

1.  Allow Medicare Patients to Use Drug Discounts

I know some lawyer somewhere is wetting his pants as I write this, but there are some really inane rules that hurt the people (read: VOTERS) who need the most help.  One of the strangest rules is the one that says Medicare patients aren't allowed to use drug discount cards.  Somewhere sometime some attorney felt that if some Medicare patients got a discount, then this implied that Medicare was being overcharged for those who didn't receive this discount.  This is like telling a grocery store that if they put some items on sale, they need to put all items on sale.  It's ludicrous.

Drug companies have drug discount cards that lower the out-of-pocket cost for their drugs substantially.  I can give these cards to people with private insurance or with no insurance at all, but my Medicare population can't use them.  It's against the law.  The drug companies are trying to get us used to writing for their medications - especially for drugs that are not real popular.  It's something called competition, and it tends to drive down prices.  You know, it's that capitalism thing they taught about in college?  These companies want market share, and so they offer discounts to get volume.  It makes my patients with good jobs and good insurance very happy, but not Medicare patients - even when they are in the "donut hole."

It would make a whole lot of people (VOTERS) very happy (likely to VOTE for you) if you made a specific exception for this (made an idiot lawyer wet his pants).  You make the laws.  You can do it.  People would get their medications, pay less, and be healthier.  What's the bad side to doing this?

2.  Allow Medicare Patients to get Free Drugs

The same inane rule that makes it impossible to give discounts also prevents seniors from getting free drugs.  Drug companies have long had patient-assistance programs for people with low income.  We have used this to get free drugs from pharmaceutical manufacturers.  Again, they do this to ingratiate themselves with the doctors and change prescribing habits.  They figure that the amount that they lose on this is offset by the goodwill from both the doctor and the patient.  They also probably have some sort of non-profit that allows them to use these donations as a tax-deduction.

Why can't we get free drugs for Medicare patients?  This would be great PR for pharmaceutical manufacturers and for you.  Perhaps you can give Pharma the ability to have a foundation that will get drugs to seniors who can't afford it.  Face it: both Pharma and elected officials like you need as much good press as you can get.  This helps you both with one fell-swoop.

3.  Fix Generic Medications

Something really strange is going on with generic medications.  It seems rational to think that generics are a big part of healthcare savings for patients.  After all, the pharmaceutical companies insist that the reason drugs are so expensive is the high cost of developing them.  If this is true, generic drugs should always be much cheaper, as they have not gone through the trial/error process of drug development.  But this system is broken in several areas:

  • In the 6 months after a drug goes off patent, one generic manufacturer is given exclusive rights to make the generic.  They have little to no motivation to drop the price, as their only competition is from the expensive branded drug.  The end result is a generic that is often 90% of the cost of the brand.  This is essentially permission to gouge customers.
  • The exclusive generic contract is now often being given to the same company that makes the brand-name drug.  This is essentially defeating the purpose of generics, extending the patent by 6 more months.
  • Insurance companies are making such good deals with manufacturers of brand-name drugs, that they are now often preferred over generics.  What's wrong with this?  Several things: first, the consumer pays a brand-name copay for a drug that is available in generic.  Second, the "deal" made with the pharmaceutical is not through discounted drug prices, but instead a "rebate" that is sent to the insurance company from the pharmaceutical manufacturer if they get a certain percentage of market share.  The drug companies compete based on how good of a "rebate" they can give (a process that in other businesses is called a "kick-back.").  The end-result is a great deal for insurance companies, but no savings passed on to the insured.

All of these problems would have a huge positive effect on the people buying prescriptions (most of them are VOTERS, by the way).  People are hurting financially - especially seniors - and cutting the costs through these measures will not only save them money, it will make it easier for them to get the drugs they need to stay healthy and stay out of the hospital.

I think this is a bipartisan win.  The liberals should like the savings passed on to the most needy, and the conservatives should like the way that these measures encourage a free-market within healthcare.

I am really sorry you guys are having such a bad time of it.  Think about what I have said; it is definitely low-hanging fruit.  You don't have to pass some huge bill to get these changes enacted, you just need to address these specific issues.  The end result would be a bunch of happy people (VOTERS), cheaper care, and higher quality.

Isn't that what we want?

Say hi to the lobbyists for me.

Dr. Rob



An Intuitive Reason for Rising Health Care Costs

I got something in my e-mail this morning. It's a press release aimed at helping with prostate cancer awareness month, and is supported by Lance Armstrong's foundation.


SUNNYVALE, CALIF.,– September 9, 2009 – Prostate cancer remains one of the most commonly diagnosed cancers in the United States. In fact, one in six men will develop prostate cancer. It is also the second-leading cause of cancer death in the United States. But a recent survey suggests that many men at risk for the cancer still aren’t aware of all available treatment options. The survey, conducted late last year, reveals that nearly 50% of men aged 40 and older are not aware of the most common approach to surgery for prostate cancer — robotic-assisted surgery to remove the prostate. “I had to do my own research and then self-admit myself to the [hospital],” says surgery patient Tim Propheter. “…. Most people are just told … ‘Sorry, you have to have surgery, and we'll set you up for such and such day,’ and they don't know any better until they run into someone like me,” he says. This lack of information persists despite the fact that prostate cancer treatment has changed dramatically in the last decade. For example, surgery — which remains the gold standard treatment for localized prostate cancer — has become much less invasive. According to the American Urologic Association, the major benefit of prostatectomy, or prostate removal, is a potential “cancer cure” in patients with localized or early stage cancer.

Guess who the press release was from? Guess who sponsored the survey? The following was at the bottom of the email:

About the survey

Data was collected from 1000 self-selected adult healthcare information seekers through an online panel available through, using an survey questionnaire. Fifty-four percent of those were male and 46 percent were female. The results reflect only the opinions of the healthcare seekers who chose to participate.

About Intuitive Surgical, Inc.

The survey was conducted by Intuitive Surgical, Inc. (NASDAQ: ISRG), the manufacturer of the da Vinci Surgical System, the world’s only commercially available system designed to allow physicians to provide a minimally invasive option for complex surgeries. Intuitive Surgical, headquartered in Sunnyvale, California, is the global technology leader in robotic-assisted, minimally invasive surgery (MIS). Intuitive Surgical develops, manufactures and markets robotic technologies designed to improve clinical outcomes and help patients return more quickly to active and productive lives. The company’s mission is to extend the benefits of minimally invasive surgery to the broadest possible base of patients. Intuitive Surgical — Taking surgery beyond the limits of the human hand.™

Imagine that. A survey done by company that sells the da Vinci robotic surgical equipment shows that men have tragically no knowledge of the da Vinci robotic prostate surgery!

So let's see what the evidence shows:

  • Prostate cancer occurs in 186,000 men each year and kills nearly 29,000.
  • In a well-known autopsy survey, over 1/3 of men over 80 were found to have cancer present in their prostate without evidence of significant disease.  It is not clear how many of these men will progress to overt cancer, but it is very clear that this is the vast minority.
  • PSA Testing (the blood test for prostate cancer screening) is by far the largest source of surgical candidates.  It is a controversial test, having a high rate of false positives and an unproven record of significant benefit.

From the reference

The European Randomized Study of Screening for Prostate Cancer (ERSPC) reported a small absolute survival benefit with PSA screening after nine years of follow-up; however, 48 additional patients would need aggressive treatment to prevent one prostate cancer death. Although the report did not address quality of life outcomes, considerable data show the potential harms from aggressive treatments. Further sustaining the uncertainty surrounding screening, a report from the large United States trial, the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, published concurrently with the European trial, found no benefit for annual PSA and digital rectal examination (DRE) screening after seven to ten years of follow-up. The crux of this screening dilemma was aptly stated by the urologist Willet Whitmore, who asked "is cure possible in those for whom it is necessary, and is cure necessary in those for whom it is possible?"

The most important line in this is at the end of the first sentence, stating that 48 patients would need aggressive treatment (including prostatectomy) to prevent one prostate cancer death.  So how much does "aggressive treatment to prevent cancer death" cost?

From the Journal of Clinical Oncology:

For patients in the treatment-received analysis, the average costs were significantly different; $14,048 (95% confidence interval [CI], $13,765 to $14,330) for radiation therapy and $17,226 (95% CI, $16,891 to $17,560) for radical prostatectomy (P < .001). The average costs for patients in the intent-to-treat analysis were also significantly less for radiation therapy patients ($14,048; 95% CI, $13,765 to $14,330) than for those who underwent radical prostatectomy ($17,516; 95% CI, $17,195 to $17,837; P < .001).

note: it was very hard to find numbers here.  This is actually from Medicare claims from 1992 and 1993, so it is a huge underestimate from today's numbers.

Which means that based on the 1992 numbers, you would spend $672,000 to save one life using radiation therapy and $1,084,000 if you used surgery.  This does not take into account the consequences of surgery for the men who underwent the surgery.

What about robotic surgery?  In a comparison of the cost of open prostatectomy to robot-assisted surgery, the cost is even higher.

Cost was the one area in which the older open surgery was the clear winner: Open radical prostatectomy costs $487 less a case than non-robotic laparoscopy and $1,726 less than robot-assisted prostatectomy.

According to the review, "Shorter operative time and decreased hospital stays associated with the robotic procedure did not make up for the cost of the additional equipment expenditure." Estimated costs of the robotic system to a provider run about $1.2 million a year, with maintenance costs of $120,000 a year and one-time costs of $1,500 a case.

To summarize:

  • Prostate cancer screening is controversial, as it fails to differentiate between the minority of men who would die from the disease from the majority who would simply die with it.
  • PSA Testing as greatly increased the number of men diagnosed with early stage cancers.
  • Prostate cancer surgery or radiation therapy is recommended for men who have early stage cancers.
  • Aggressive prostate cancer treatment has to be done 48 times to save one life.
  • The most expensive treatment for prostate cancer is prostatectomy, or removal of the prostate.
  • The robotic form of the surgery is a higher-cost procedure by a significant amount.

So, an expensive form of surgery that may not be appropriate is done on a group of men identified on a very unreliable test yielding a very small number of lives saved and a lot of men who then have to deal with the physical consequences of the surgery.  Why in the world is this being promoted at all?

Money.  Here's the homepage of one of our local hospitals.  They have aggressively marketed da Vinci surgery on television, billboards, and the radio.

Why do you think they would pay as much money as they do for this device?  It's good business?  Not so fast.  Dr. Paul Levy stated back in 2007 about this very procedure:

Here you have it folks -- the problem facing every hospital, and especially every academic medical center. Do I spend over $1 million on a machine that has no proven incremental value for patients, so that our doctors can become adept at using it and stay up-to-date with the "state of the art", so that I can then spend more money marketing it, and so that I can protect profitable market share against similar moves by my competitors?

No, hospitals are employing this just to keep pace.  The real winner in this is Intuitive Surgical, Inc., who has been a darling of Wall Street, beating estimates in earnings with a Q2 net profit of $62.4 Million.

Why is the cost of healthcare going up while physician reimbursement goes down and hospitals go out of business?

It's Intuitive.

God Bless America!