Archive for February, 2013

Bitter Pill — redesign of health care

A fantastic article about US health care was published this week.

Time Magazine March 4, 2013 “Bitter Pill:  Why Medical Bills are Killing Us” by Steven Brill

There are two main lessons from Mr. Brill’s article.  First, as a business, US health care is doing quite well financially.  Second, the overwhelming drive for profit is bankrupting patients and the US economy.  He makes a damning case US healthcare has disconnected the actual cost of care from the high charges for care.  Mr. Brill has exposed the unethical side of US health care.

If  Mr. Brill’s article has a weakness it would be the suggestions for correcting what he has found.  He proposes a few solutions but he acknowledges, as a journalist, he was not looking for solutions.  However, he is on the right track — the US clearly needs to redesign the health care system and, he makes a very good case for Medicare as central to any effort at cost containment.

The following suggestions for redesigning our health care system spring from the collision of high cost, poor quality and the belief an expansion of Medicare will help to solve the crisis.

1. Allow all citizens to buy into Medicare at any age (some would pay more than others according to risk and ability to pay)
2. Mandate that all health care subsidized by the US government (Medicare, Medicaid, postal workers, veterans administration, indian health care etc) is covered by Medicare (consolidate the vast array of  plans to just one — make it simple and manageable).
3. Allow the States to purchase Medicare for their workers — a big cost savings for the States.
4. Mandate employers to provide healthcare for all workers — Medicare would be an option  — but  the health care benefit must be at least as good as Medicare.
5. Allow the FDA to evaluate drugs, devices and equipment for cost effectiveness and to make a Medicare listing of those items that are covered (those that are not listed can be purchased by individuals outside of Medicare).  The FDA would be required to make the cost of the list stay within a maximum stipulated by Congress).
6. Allow Medicare to negotiate the purchase price of drugs, devices and equipment nationally.
7. Force the creation of Accountable Care Organizations immediately.  All Medicare benefits must flow through ACOs.  This solves the payment for volume of services problem.  There has been a delay to “see if ACOs work”.  Similar systems are well proven in other countries, we just need to act.
8. Physicians and hospitals who provide Medicare should be employed by, or under contract to, an ACO.
9. All physicians who work full time under Medicare will be salaried at $200,000/year with an additional $100,000/year  awarded (or not) if established quality and service targets are met.  For example, there is no pay differential for primary care and neurosurgery.  (this payment system works wonderfully in the UK).
10. Establish a copay for primary care, specialty care, ER care, hospital care, SNF etc to incentivize a primary care home, and to put a clamp on overutilization.  (the poor may get coupons, like food stamps, for the copay)
11. Increase the nurse practitioner and physician assistant workforce as quickly as possible.  It only takes 3 years after college for them to be care providers whereas it takes 7-10 years for physicians and surgeons.  Offer to pay for physician training if they will be Medicare doctors for at least 10 years in locations where Medicare finds a need.
12. Mandate a national medical record for Medicare
13. Mandate a national health card — show the card at the point of care, pay the copay and get the service — no paperwork!
14. The US needs to think of health care as a right — a right to reasonably priced health care!
15. Monitor quality for Medicare and push the quality agenda so the US can again have the best quality health care.

Those are my thoughts for a big-picture redesign.  What are yours?


A few links of interest:

Diane Archer (Board of Directors, Consumer Reports)
Bitter Pill:  5 part series (a blog)
Naomi Freundlick (Reforming Healthcare Blog)
Bob Haiducek  (Medicare for All)
James Kahn (Physicians for a National Health Program)

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Errors at the Pharmacy — what is that pill?


Assume you just picked up your prescription for pills at the pharmacy.  The bottle has a label with a drug name, dose and how often to take it.  But, is the pill the right one, the one the doctor had in mind?  Or did somebody make a mistake and put the wrong little green pills in your bottle?  Or perhaps the bottle has the wrong label?  Did you actually get the pills Dr. Jekel prescribed for Mr. Hyde?  Just to keep this in perspective the picture above is of the same medication: losartan;  made in different strengths and by different manufacturers.  Pharmacists do their best to keep the pills straight but they are only human.

To err is human.  But, in most medical situations the goal is an error rate better than 1 in a million.

million (1)

The rate of uncorrected pharmacy errors is much worse:


The estimate of errors varies widely, see the article by James et al.  The 1 error in 33 prescriptions (3%) is an overall estimate of  errors (like the wrong directions on the bottle).  An article by Flynn et all notes “An estimated 51.5 million errors occur during the filling of 3 billion prescriptions each year.”  Death resulting from these errors is unlikely but still is reported.  In everyday terms a local pharmacy will make dispensing errors several times a day.  Large automated pharmacies actually do much better, sometimes in the range of 1 error in 100,000 prescriptions — not too bad but still not good enough.

What can the prescriber do?

  • Always discuss prescribed medications with the patient
  • Tell the patient why each medication is needed
  • Give the patient a complete list of medications and
    indicate which are new, changed, or just continued
  • Send prescriptions electronically

What can the patient do?

  • At the prescriber office or when leaving the hospital
    • Get a complete medication list (or make a list yourself)
    • Record why you take each medication
    • Understand if the medication is scheduled
    • or just taken as-needed for some symptom
    • Record the drug name, dose and how often to take
    • Are you getting enough refills to last until next visit?
    • Ask what the top 3 side effects might be (printed list of a zillion possible side effects is nearly worthless)
  • At the pharmacy, before paying for the medication:
    • Look at the medication bottles and verify
      • Your name
      • The prescribers name
      • Drug name, dose, how often to take
      • Confirm this medication is for your known diagnosis –“this one is for my high blood pressure, right?”
      • Is the quantity and number of refills correct?
    • Ask to look at the pills themselves
      • If this is a refill the pill should look the same as before
        • if not, why not?
    • Did all the prescriptions the doctor prescribe get filled?
    • If you are getting a new medication always allow the pharmacist to talk to you about the medication
    • If the medication is an inhaler ask for instructions and a demonstration
    • If the medication is an injection ask for instructions
    • If the medication is a liquid ask how to measure it
    • If the medication costs $100 a dose or more you have a right to know where it was made and what precautions were taken to avoid counterfeit medications.
  • At home
    • Read the information you were given about the medications
    • ID your pills with an online pill identifier like
    • If you find errors, obviously, contact the pharmacy immediately
    • Report medication errors to the ISMP (Institute for Safe Medication Practices) or if severe to the state pharmacy board.
    • Report pharmacy errors to your prescriber

If you have experienced errors or have other suggestions to avoid errors please leave a comment.

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Drug Reps — it’s in the details

devil rep

What Are Drug Reps?

They are the sales force for drug companies called drug representatives.  They visit prescribers and hospitals and health plans or anyone perceived as having the ability to influence the use or purchase of the company medical or surgical products.  When they sell surgical products the word “drug” is changed to “device” or “equipment” or “training”.


What is the ecology of drug reps?  What do they look like?  What is their habitat?  They seem to live in doctor’s waiting rooms.  The large briefcase, the laptop computer and the perpetual smile are the hallmarks.  They can be tracked by the trail of ballpoint pens with drug logos.  The men are rugged-looking and wear fashionable suits.  The women are good-looking with tailored short dresses.   They seem to whisk back to see the doctor no matter how busy the schedule and no matter how difficult patients have in getting an appointment.  If only patients could be so pleasant.

Friend or Foe

Are reps the patient’s friend?  Absolutely not.  Their only allegiance is to the product they sell.  The reps job is to minimize the side effects, the hazards, the opposing research, the deaths, and the cost of what they sell.  They visit prescribers as a friend, someone who admires the prescriber, and someone who thinks the prescriber is smart and sexy.  They give gifts and provide meals if the prescriber will listen to an “educational” presentation.  The reps suggest only fuddy-duddies stick with generic drugs.  Primary care providers are told the specialist the provider likes always prescribes the drug the rep sells.

No Visits, No Samples

If providers do not see reps the providers actually could get excellent  unbiased recommendations from several sources.   But, those sources (like subscription news letters) cost money and don’t come with a good-looking sales person.  Furthermore, free samples are not given to those who fail to see the company rep (no matter what the drug companies say).   Then patients gripe “why don’t you give me samples like the other doctors?’ — even the patient becomes a sales person!

Marketing Surgeons

A new device is a marketing problem.  The surgeon who might use the device does not want to travel to see the device.  So, the device comes to the operating room.  The sales person demonstrates the device and talks the surgeon through a procedure (while the patient is under anesthesia).   Or, with certain inducements the surgeon goes to a course on the device and, amazingly, they get a certificate saying they are proficient with the device — do surgeons every fail these courses?  Of course not.  And, hospitals rarely question the certificates, after all, the hospital did not pay for them.  Should patients feel comfortable with the level of training? No.

Doctors Like Reps

When doctors are asked about industry reps they say they need the information provided and like to ask questions about drugs or devices.  And, they are not influenced by the sales effort.  But, drug companies know better and continue the very successful sales technique.  So, the drug reps march on.

Free Training

Hospitals like surgeons to start using new procedures, especially if they do not have to pay for the training.  New procedures often have higher reimbursement than old procedures which are more time-consuming.  Thus, more money for less work — who approved that higher payment anyway?  The reps help surgeons inform the insurance company  about new technology “revolutionizing” treatment — denial of such an advance would not look good to regulators.  And regulators are sent fact sheets about the new procedure  insurance companies want to cover.  So the reps march on.

Hospitals Are No Match

The sales techniques for hospitals or drug suppliers are diabolical.  A one-of-a-kind drug is pared with a drug made by the same company which has lots of competition.  If the buyer purchases the two drugs together they get a discount on the high-priced item.  Another favorite tactic is to bundle a whole group of medications — the deal is if the buyer will use that group (like antibiotics) to the exclusion of competitors they get a good discount.  When a competitor invents a better medication the buyer is faced with huge losses to make a change just for one drug.   This market-basket approach undercuts the competition – often driving smaller drug companies out of business.

So Why Are They Bad?

Why are drug reps bad for patients and the U.S. health system?  Because the marketing target is the prescriber not the payor.  The prescriber does not pay for the medications or device, they don’t suffer the side effects, and they don’t die from complications.  As a group they are easy marks for sales.  The failure of adequate drug evaluation (cost-effectiveness) is extremely wasteful both in terms of the cost of care in this country and the health and financial well-being of patients.

Nobody Does It Better

In England purchasing is done by a national agency that evaluates medications for cost effectiveness.  The very reasonable English seem to have a grip on the problem.  The disorganized U.S. health system is no match for the marketing efforts.

What Can Be Done?

  • Clinics and hospitals  should not allow drug reps to visit
  • Clinics and hospitals should provide unbiased drug and device newsletters for the physicians and surgeons
  • Hospitals should pay for surgeon training for new procedures
  • Patients should be happy a doctor does not allow drug reps and accept the fact samples are actually costing money indirectly.
  • Clinics should be able to obtain (or purchase) samples of drugs needed (like for demonstration of inhalers or medication injection techniques)
  • Hospitals should participate in large purchasing organizations and follow the recommendations of third parties who advise on drugs and devices.
  • Government health plans  should have a nation-wide formulary.  The cost of drug and device evaluation is too high to allow duplication by every insurance plan or government department.
  • Market-basket sales techniques need to be stopped due to the anti-competitive effects.  One drug, one price, should be the rule.

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Population vs. Patient Care — art no more


The U.S. has always been concerned about population health but mostly in terms of clean water, safe food, and safe medications.  Outside those areas the art of medicine was left to doctors.   There have been lots of medical discoveries in the past 20 years.  But, one quiet discovery may be the most important:  medical care is not art.  It may be industry or business or paint-by-numbers but it is not art.  There are rules and there are expected outcomes.  And, most importantly, the rules can be applied to populations.   For example, there are necessary vaccinations, unacceptable blood pressure levels, excessive weight ranges, best ways to remove gall bladders, and the correct frequency for pap smears.   There is a glimmer of hope that a focus on population health management will reverse the trend of rising health care cost.

An article from the University of Rochester Medical Center is a very nice perspective on population health.   They see the future of health care in systems of buildings, information technology, and organization of primary care.  The theoretical underpinning is reliability, interchangeable parts and operational efficiency.  The tools are there for controlling cost.  But, those tools currently are used to increase profits,  somewhat like letting the fox guard the chickens.

Patient-centered care  emphasizes efficiency and satisfaction at the point of care which mirrors our cultural view of individual importance.  In some respects this is consumerism or “give the patient what they want”.  Quality is the byword and standards for such care have been outlined by the National Committee for Quality Assurance (NCQA).  Important aspects of care include evidence-based guidelines, access to care, timely appointments, after-hours care, coordination of specialty care, continuity of care with one provider, cultural sensitivity, and good record keeping.  All laudable goals but mostly unconcerned with cost.

Each country must find its own path to good quality low-cost health care.  Our neighbor to the South, Cuba, is an interesting case.  The Cuban medical system now has twice the number of doctors per person as in the U.S.  so Cubans have better access to care than we do.  They even have lower drug costs because the government manufactures low-cost medicines.  The path they took is not likely the one the U.S. will follow since Cuba has poor sanitation, high poverty, 70% of employment is by the government and doctors are only paid $20 per month.

The cost of care must always be considered.  The population health advocates assume good systems and management will lower cost.  The patient-centered advocates assume quality care is less expensive care.  The path the U.S. needs to follow should include a blend of both, plus guaranteed (not theoretical) cost containment.  The cold hard fact is our health systems must be trimmed, our provider workforce must be expanded with less expensive providers, and new drugs must cost less.  This is a hard pill to swallow but we just need to take our medicine.

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