The purple pill tops the list of the most expensive drugs for government health programs in 2013. No, your first reaction to blame the government is wrong — the drug is prescribed by health care providers — and, the government is prevented by law from negotiating drug prices. Why is this a problem? –there was a perfectly fine OTC generic substitute available in 2013 at only 6% of the cost.
WHAT??? Prescribers wrote prescriptions for a drug that could have been substituted by an equivalent drug and saved 94%. OK, at the margins of the argument, at the fringes of reality, at the level it makes no clinical difference, big pharma says it might not be a perfect substitute. A good example where the “perfect” is the enemy of the very good.
But, how could prescribers and patients have the wool pulled over their eyes? — fantastic marketing. And, by the way, if you take this drug, send me your name, address, social security number, and bank account number, I have a nice bridge to sell you.
The magnitude of the problem became crystal clear when CMS published prescription data. The following data is widely reported from CMS as the spending on drugs through Medicare’s Part D prescription-drug program in 2013:
|Rank||Brand Name||Generic Name||Number of Claims||Cost in Billions|
Omeprazole is a very good substitute for Nexium for heartburn and reflux. Despite the cloud of industry generated studies many pharmacists say the two drugs have equal effects. As the table above shows omeprazole was prescribed 4 times as often as Nexium but the providers who chose Nexium created a vastly larger and unnecessary cost. Why Nexium is even be on the Medicare Part-D formulary is a mystery. Who pays the bill? — taxpayers, of course, and the patients who paid a co-pay higher than the full cost of an equivalent.
In 2015 Nexium became an over the counter drug (OTC) and just as you might suspect it now costs about the same as OTC omeprazole — about $32 for 56 pills (at Costco) rather than $300.
Where is the oversight? Where is the cost control? Why is US healthcare so expensive? Need more examples? Just look at the other medications on the list.
Switching from a brand name medication to an available generic medication is safe, easy and will likely save you a lot of money. Thanks to the work of the FDA, generic medications in the United States are quite safe. Patients in the US take more generics than in other countries.
When a patient starts a new brand-name drug (e.g. Lipitor) there is a risk of a side effect or allergy to the active ingredient. But, when a patient switches to a generic medication (e.g. atorvastatin) the patient already knows the active ingredient agrees with them so the chance of a reaction is as close to zero as medical science can make it.
Prescribers are well aware that some generic medications may come in different forms (tablets or capsules) and different strengths — this is not a problem, the prescription just has to be adjusted to match what the patient needs. Most care providers are quite willing to make the change to help lower the cost of treatment — patients tend to take medications they can afford!
The Wall Street Journal had a story today based on the opinion of a “pharmacist-economist” who has been a lead author on only one paper in the past 20 years and who thinks tablets and capsules of the same medication are distinct entities (yes, but it makes no practical difference). The WSJ is clearly interested how the switch to generics affects the economics for big pharma — it would not be good and the stocks could go down — such a disaster. However, if you have stock in a brand-name company you could use your stock dividends to pay for the drug.
The new bio-similar drugs and even some old drugs (like warfarin) may have a slightly different effect that depends on some minor manufacturing quirk. Prescribers are well aware of these peculiar drugs and can easily make adjustments and do tests as needed. Fortunately, small manufacturing differences for the vast majority of drugs is a distinction without a difference for the patient.
This principle needs to be considered in everyday terms. The table salt at restaurants may come from separate and distinct sources — it really makes no difference to the customer — salt is salt! Marketing departments want you the think a generic is like coal and a brand-name is like diamond — intellectual garbage.
One ER visit is a red flag — more ER visits for the same problem become an example of poor quality health care.
Urinary difficulty is something older men don’t like to talk about. But, 1 in 10 men over the age of 70 will end up in the emergency room with urinary retention — an uncomfortable situation where they can not pass urine. Urologists are aware of this frequent problem — see the billboard story. It is a serious problem; in third world countries it may be fatal.
The usual cause is enlargement of the prostate preceded by symptoms of slow and frequent urination. Sometimes there are few symptoms until a painful inability to pass urine forces a rush to the emergency room.
The usual medical approach is to insert a tube (a catheter) into the bladder to relieve the pressure, start a medication to help urination, and 3 days later to remove the catheter. 50% of men can then pass urine adequately (for a while). The quality issue is that 50% have a recurrence within a week — so is another ER visit the answer?
A friend of this blogger landed in the ER a total of 4 times with urinary retention. Why is the ER the center of after-hours treatment for this problem — once identified as an issue why is the health care system making it a recurring emergency?
The solution is Urologists need to own the problem and provide adequate patient care 24 hours a day once a catheter is removed. Yes, own the problem, not turn off the phone and let the ER solve it. Does that mean the urologist must be at the clinic 24 hours a day? No, but there must be an arrangement for immediate care — no waiting in the ER, no ER charges, no secondary consultations. An arrangement with a 24 hour urgent care center may be enough but some back-up plan and patient education are essential.
The majority of men with urinary retention end up having a surgery to ream-out the prostate (TURP). According to healthcare-salaries.com a suburban US urologist makes $500k to $1M each year. This is another example of the decoupling of cost and quality caused by involving multiple providers with no common financial risk.
A proactive patient who has a catheter removed should ask the urologist “what is the plan if this does not work?” and “is there some alternative to the ER since you have already evaluated me?”. At least find out how to get in touch with the on-call urologist!
Moderate fitness is the most powerful treatment to prevent disease. And, moderate fitness is easy to obtain. Just walk 20 minutes a day. People get very little extra benefit from more exercise than that! The graph shows moderate fitness lowers your risk of death by about two thirds — and the extra years you get will have better quality.
The benefit of moderate fitness exceeds that of not having the following conditions:
- high blood pressure
- high cholesterol
- family history of heart disease
So what worries you more? Being a couch potato or having any of those conditions? The couch potato is the worst. This is not to say you should continue smoking — it means you need to BOTH exercise AND stop smoking.
The average American watches 5 hours of TV per day and many think the lack of activity it causes increases the death rate. Just skip one TV show and walk instead to reverse the trend.
A good primary care provider should ask you about your level of exercise and fitness at every visit. A lack of fitness is the most severe health problem in the United States. Health providers almost always check you blood pressure when in fact your level of activity is more important — let’s keep this in perspective.
Here is an absolutely wonderful YouTube video about fitness:
Too much treatment is dangerous just like too little treatment. Treating blood pressure too early or too aggressively increases the risk of death. Treating elderly patients with diabetes with too much medicine increases episodes of low blood sugar that damage the brain and leads to broken bones from falling.
In 2014 the national guidelines for blood pressure treatment were changed to allow a higher blood pressure. Similarly, a recent study found increased mortality for elderly patients treated too strongly for diabetes.
This is not rocket science. Imagine a blood pressure medication that could lower the blood pressure to any level. Knowing that zero blood pressure means you are dead, it stands to reason there is a point where treating blood pressure goes from helpful to dangerous. Same for blood sugar.
Sometimes this problem is called “treating the test“. In essence prescribers just look at the numbers and write a prescription, but ignore symptoms of weakness or spells of altered consciousness. Hypertension and diabetes are good examples but this happens with lots of other conditions.
Examples of over-treatment include treating a sore throat with antibiotics, treating mild asthma with oral steroids, or treating an elevated lyme serology test with antibiotics. It takes time to make a correct diagnosis and time to explain treatment to patients — some health care providers simply don’t take the time to do either.
Most drugs have a “therapeutic window“. As long as the window is open the patient gets benefit. But, the window closes due to side effects and advanced age.
If a person is over 80 or in poor health excessive medical treatment is a substantial risk. In this group even the thought of a low cholesterol diet is foolhardy. It’s all about risks and benefits.
The 2014 data from the United Health Foundation is in. The graph rates health status of people in all 50 states . Hawaii, the state with a virtual single payer, is #1 and Mississippi with poverty and poor access to care is #50. The rankings aggregate 27 measures including physical inactivity, infectious diseases, immunizations, number of primary care physicians and disparity in health status.
Addendum (2/26/15): After creating the above graphic I realized it was virtually the same as one in a previous blog. The first graph was from the Commonwealth Fund intended to show regions of poor quality care (e.g.patients not given adequate immunizations) and the second was from the United Health Foundation intended to show patients having poor health (e.g. patients not taking immunizations). In the first it says the health care system is not doing enough, the second says the health care system is overwhelmed by problems. I tend to side with the Commonwealth Fund. When you find yourself surrounded by alligators it is important to recall your first job was to drain the swamp, not to later just complain about alligators. Good advice for the Mississippi legislature.
The long and difficult training for surgeons often leaves them with little intrinsic drive to improve surgical care. Anyone who has had to discuss surgical quality with practicing surgeons is lucky to leave the discussion without a fear of losing their job. So, with little intrinsic drive to improve quality, the government and insurance companies resort to the old carrot and stick methods.
For surgeons the carrot and stick are financial. So, if a surgeon and associated hospital have patients that are readmitted within 30 days the hospital is penalized — the hospital is unhappy and verbally passes that unhappiness on to the surgeon.
A study just published “Underlying Reasons Associated With Hospital Readmission Following Surgery in the United States” expresses surgeons’ negative opinions of the penalty saying it really won’t have much effect on surgeons — wow, what a stonewall attitude!
The argument is based on the findings that surgical patients return to the hospital because of an infection where the skin was cut or because of bowel problems from pain medication. Somehow, the surgeons writing the article seem to think complications, coming to light after the patient leaves the hospital, are beyond their control — so the hospital should not be penalized. In other words, complications are and ACT OF GOD.
Wrong answer! Patients, families, insurance companies and Medicare do not want to further enrich surgeons and hospitals for bad outcomes. A much better answer would be to double the efforts to improve quality and reduce complications and to have surgeons spend more time out of the operating room figuring how to improve surgery in the operating room.
Admiral David Farragut is attributed with the phrase “damn the torpedoes, full speed ahead” — was he really a surgeon in disguise? We all know intrinsic motivation (dedication and innovation) is much more effective than extrinsic motivation (carrot and stick). Intrinsic motivation comes from training programs that place emphasis on quality and downplay personal profit.
The solution: surgeons should be employees of the hospital (an ACO model) so they personally feel the financial pressure to minimize costly complications — not just watch as the hospital is penalized. And, improve post-graduate surgical training to have more emphasis on quality.