Archive for April, 2014

Insulin pumps for diabetes — the cost of health

insulinpumpElisabeth Rosenthal of the New York Times published her article “Even Small Medical Advances Can Mean Big Jumps in Bills” on April 6, 2014.  Type 1 diabetes is a rapidly fatal illness without insulin treatment.  The discovery of insulin in the 1920’s changed the disease from fatal to treatable and with improved insulin and improved devices to deliver the drug people with the disease now can look forward to a long life.

The article by Ms. Rosenthal points up the cost of current insulin pump therapy.  She lists the yearly cost of insulin treatment for one woman as $26,470 (a large part paid by the woman’s insurance).

Surely, big pharma would not take advantage patients with life threatening illness like diabetes.  Surely, they would not pad the bill with unnecessary equipment or lock-in patients to their brand of insulin with a device linked to that brand.  Surely, US big pharma would not disadvantage US citizens and favor drug plans in other countries.  WRONG, WRONG AND WRONG AGAIN.  It’s the modus operaindi of such organizations and a lack of regulation that allows it to happen.

  • Ms. Rosenthal comments on the fluff added to the bill:  talking pumps with multiple colors and new models every year.
  • The linking of insulin pumps to only one type of insulin (made by the insulin maker).
  • The withdrawal of less expensive insulin from the market.
  • The 70% profit on insulin.
  • The limited number of companies that now make insulin.
  • The sweet deals for countries that drive hard bargains (acquisition cost for a bottle of insulin in the UK $30 but in the US $200).

It seems there is a line to be drawn.  On one side is the unquestionable benefit of research and development that brings fantastic life saving benefit to many patients.  On another side is a business formula for fantastic profit to a few people.  Fortunately, one need not choose either extreme — it is possible to have adequate research and reasonable profit as demonstrated in other parts of the world.

So, what can and should be done?

  1. Break up drug companies to separate the manufacture of insulin and the manufacture of insulin pumps.  The competition in the pump market should not be limited by the drug maker.
  2. Limit drug patents with a strict end point and encourage smaller companies to make generics that may not be an exact copy but simply be similar (bio-similar).
  3. Set prices for drugs and devices based on realistic economic considerations (like limiting profit to 5%).
  4. Allow government sponsored research to compare various types of similar therapy to allow a reasonable choice by patients and providers.
  5. And, allow the government to negotiate prices since the government now pays a big part of health care costs.

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Leaving the hospital — what meds to take?

medlistHospital medication errors are very frequent.  A commonly quoted figure is one error every day of a hospitalization.  Meaning: wrong drug or wrong dose or wrong time or missing dose.

Consequently, it should not come as a surprise  the instructions patients are given when they are sent home have frequent errors.  Patients may be taking medications before they are hospitalized, so in addition to new medications those pre-existing medications need to be considered (a process called “medication reconciliation”).

You may ask:  how can this be goofed up?  A person has medications at home, the doctor writes a new prescription just before going home, the prescription is filled by the local pharmacy, and the prescription is taken in addition to the same medications as before.  What could be more simple?

The answer is: there is plenty of room for error!  What if:

  • the new medication is actually a generic duplicate of a brand name home medication
  • the new medication has severe interactions with a home medication
  • the home medication dose is listed incorrectly
  • the new medication prescription and the discharge instructions don’t match
  • a new medication prescription was omitted
  • a doctor outside the hospital is unaware of the new medication and prescribes something that interacts badly
  • the patient get an allergic reaction to the new medication but the prescriber is not available to help
  • the patient forgot to mention some of the home medications
  • unnecessary brand name drugs are prescribed that are not covered under the outpatient insurance plan
  • the prescriber forgot to tell the patient to stop some of the home medications that were causing symptoms prior to hospitalization

NOT SIMPLE AT ALL.

Yet, hospitals and prescribers often don’t take much time to get the medications right at discharge (there is a big push to get the patient out the door as soon as possible).  Here is an actual example from 2 weeks ago:

A patient was admitted from a care center with an accurate list of medications.  The admitting nurse transcribed the list into the medical record but made a mistake on one dose.  The physician’s plan was to reduce the does of another medication which seemed too strong but the patient was not taking any medications by mouth at that point so no medication orders were written.  A few days later the patient was ready to leave the hospital.

Unfortunately, a different physician discharged the patient rather than the one that admitted the patient.  The nurse’s list of home medications was used to generate the discharge medication instructions — no new medications were ordered.  But, the transcription error of the nurse was included with the instructions and the plan to reduce the dose of another medications was forgotten.  Two major errors.  The family actually realized the errors but the nurse the family informed forgot to call the doctor so no change to the list was made so the care center followed the flawed instructions.

So what went wrong?

  1. Duplicate lists of home medications were collected but the transcription error was not detected because the lists were not compared.
  2. The list of medications used during the hospital stay was not marked as equal to or changed from home medications.
  3. The planned change in home medications was not made because there was no place to put such a reminder for discharge in the hospital chart.
  4. The prescriber did not review the medications with the patient or family personally.

Worse yet, although errors happened there was no plan to change the system to prevent similar errors in the future.

So, as a patient or family member what can you do?

  1. ALWAYS bring multiple copies of an accurate list of home medications to the hospital — give a list to anyone that asks to review the medications.
  2. Expect the attending physician to review the discharge instructions with the patient or appropriate family member — if this does not happen immediately complain and make that expectation known.  Good physicians plan ahead and sometimes do this review the day before discharge!
  3. Use one of the copies of the home medication list to compare to the discharge instructions.  Make sure to understand ANY changes.  And ask — does the new medication, if any, interact with home medications?
  4. Find out who to call if questions or problems with the medications arise after getting home — get a name and phone number.  Often the discharging nursing unit will take the call and find the right person.

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