Archive for category Specialty Care

Specialty Drugs — at a price you can’t afford

specialtydrugcostBig Pharma blows the lid off the price for “specialty drugs”.  Those drugs now cost more than an average American’s income.  By 2020 the average specialty drug will cost $80,000 per year, just pray you don’t need two of them!

The data plotted above come from AARP.  The raw data is concerning and three questions beg to be answered:  WHY is this happening, IS THIS A PROBLEM and if it is a problem WHAT IS THE SOLUTION.

WHY?  — because big pharma wants to make a lot of money.  Somewhere, long ago and far away, some researcher wanted to help people with difficult medical problems.  But, that altruistic thought was crushed as the drug was marketed.

PROBLEM? — absolutely, the US healthcare system can not afford the drugs and neither can average individuals.   If a drug costs a trillion dollars it’s not a drug, it’s a joke.  So where is big pharma going wrong?  Here are some possible choices:

  • Too much is spent on research
  • Too much is spent on advertising
  • Too much profit is paid to shareholders

Where is US healthcare going wrong?

  • Too little regulation exists to require cost effectiveness research before marketing drugs
  • Too little drug price control is being exerted by the government.
  • Too little mirroring of price controls in other countries that shift profit taking to the US.

SOLUTIONS?  — if the trend is allowed to continue “Bronze” health insurance will not cover specialty drugs but “Platinum” insurance will.  Sadly, only the top 1% will be able to afford the “Platinum” plan.  The US will have more of a two tier healthcare system with a huge gap between the 99% and the 1%.

  • Impose cost controls on drugs — extremely high priced drugs should trigger rules to lower profits so such drugs will either cost less or not be produced.
  • Demand cost benefit analysis on all drugs before marketing — if the benefit is not worth the cost then don’t add them to the formulary for Medicare or Medicaid.
  • Wrap drug costs inside health plans.  That way other factors get consideration, like preventive care,  hip surgery, simple childhood vaccinations,  and pregnancy.  The big pharma bill should not be coming “off-the-top”.

 

 

 

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Surgical Consultation — when is the right time?

Hhammerwithnailow to make a surgeon cry:  “I don’t want surgery.  What should I do about my hip pain?”  Surgeons are faced with this question every day.  Most of the time the answer is “well, when you are ready you can always come back.”  To be blunt, surgeons are trained to do surgery and surgeons lose money when they spend time doing something else.  In fact, they often don’t have much experience with the “non-operative” management of many conditions.

Think about the problem.   Would you ask a butcher what he would recommend for a vegetarian meal?  Would you ask a home builder about the best apartment to rent?  Would you ask a car mechanic about where to drive your car for a vacation?  It is possible the butcher, home builder or car mechanic will have a good answer but chances are not too great.  So why would this be different with surgeons or other specialists?

The general rule is to ask someone a medical questions who does not have a vested interest in the answer.  Or to do a good job of investigating symptoms on the Internet before getting a consultation so you can ask good questions and be “a little” skeptical.  A primary care doctor’s office is the first place to pose the question.   If the primary care office in uncertain about a diagnosis then a higher level consultation is in order — the question to primary care should be “who would best be able to guide me to the next step?”  Like, “I am having some mild hip pain.  I don’t want to consider surgery yet.  What non-operative treatment is available?”

Recently a friend was having knee pain.  She saw her primary care provider who suggested cutting back on hiking.  That did not seem very high tech so she saw a surgeon who recommended surgery.  Since the knee MRI was normal she was skeptical.  She took some Tylenol and a few weeks later the pain was gone.  The old saying “if you have a hammer then everything looks like a nail” is very true in the procedural world.

Another example comes from gastroenterology.  If a patient has gas and bloating which do you think a gastroenterologist will do first:  a $1000 colonoscopy or trial of a dietary change?  — you guessed it, often the colonoscopy!  Worse,  if the colonoscopy is normal you will likely be sent to primary care to try some dietary changes and some lab tests.  The appropriate route to take is to let primary care suggest the diet changes, get some lab tests and simple x-rays.  Then, if the problem is still not solved go for the colonoscopy.

In health care systems where physicians have a  financial incentive to provide quality and follow evidence-based guidelines the number of unnecessary procedures declines.  Surgical complications are probably higher than you realize.  Taking time to seek answers before getting that surgical consultation is very important.

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The $9,000 Colonoscopy — lighting the way for profit

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$3,500 is the amount US insurance companies pay  for a screening colonoscopy that takes 30 minutes.   In some states a $9,000 charge is routine.  In the country of  Switzerland the cost is $655 using the same techniques and the same scope from Japan.  This sad story of price gouging was reported in detail by the New York Times on Sunday June 2, 2013.

Key points about high charges from the Times’ article include:

  • Adding charges for an unnecessary anesthesiologist
  • Adding facility fees by calling colonoscopy a surgery
  • Adding huge fees for biopsies that take only minutes
  • Repeating colonoscopy too frequently

If it was just colonoscopy that was the cause of the problems with high cost in the US  it would be an easy fix.  But, the pattern of prices having no basis in actual cost is a systemic problem of huge proportions.

In other walks of life people would not tolerate the abuse.  We would complain bitterly if a garage mechanic charged for someone to hold his light, or added a fee to use the garage space,  or tacked on a charge to check tire pressure  or wanted to recheck the muffler every 3 months.

Why do people tolerate unreasonably high medical prices?  Because people do not understand health care.  Because insurance shields them from the need to understand.  And, because we think 10 years of training is needed to do many procedures, which is absolutely not true.

Surgeons and gastroenterologists study many things but if colonoscopy was separated out, the total training time for that procedure itself  is probably only a few months.  A trained physician assistant or nurse practitioner could easily do a screening colonoscopy at much lower cost and with equal safety.  The manpower drain from gastroenterology to do screening colonoscopy  is astounding and the only reason they do it is the high reimbursement.

Keep in mind, it is not people causing the problem.  The fault is with the warped system of care and reimbursement we have devised.

To fix the problem the US system of payment must change to be more like other advanced countries.  That means  either the prices for procedures are set nationally (the French way) or large conglomerates of doctors and hospitals are paid to provide all necessary care to people on a per capita basis (the ACO way).

Numerous publications are reporting on the problems in our health care system.  The New York Times, The Wall Street Journal and Time Magazine have had lead articles on the subject.

The problem of high cost will need government action to make a significant change since no business is large enough to force the issue alone.   It is easy to be pessimistic — but, there is a tipping point coming.  When consumers realize lower-cost  higher-quality health care is possible they will want it.

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Why People See Doctors — it’s not that deep

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Question:  What is the number one reason people see doctors?

  • a)  because they have a life threatening health problem
  • b) because they are obese and want to lose weight
  • c) because they don’t get enough exercise and want an exercise program
  • d) because they have a skin problem

According to an article in the Mayo Clinic Proceedings this month the answer is “d”.   42.7% of visits are due to skin disorders.   You should have known the answer just by looking at the magazines at the grocery checkout counter or watching ads on TV.  We worry about skin blemishes but in the past people had to worry about smallpox or TB.  It is hard to be serious about health care cost and political change in the face of this statistic.  OK, acne scars are bad and skin cancer is real.  But, the real danger from skin problems is very low.  What can be done to alleviate skin problems without spending half of the U.S. GDP on trivial office visits?

The Mayo Clinic Proceedings article tangentially mentions dermatology telemedicine.  Great idea.  A picture is indeed worth a thousand words or perhaps a thousand patient visits.  What if there was an app for taking a picture of a skin lesion and sending it for a dermatology consult ($10).  Think of the cost savings for simple advice for acne or eczema or diaper rash!  The improvement in health literacy would be huge and visits to primary care would decline.  If a visit to primary care proved to be needed it would be for a substantial skin problem (or something else).  Any health system wanting to reduce cost should find this idea fantastic — any health systems out there actually doing this?

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Hospital Care — who’s in charge?

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Diagram of the Multi-Team System (MTS) for patient care is from the AHRQ web site.  This is an idealized concept of what should happen that often does not happen.

A recent article in the New England Journal of Medicine (NEJM) described an unfortunate but all too common situation in hospitals.  In this article a patient was very sick in the intensive care unit with respiratory failure (on a ventilator) and with an unusual skin rash.  40 doctors and far more nurses were involved in the patient’s care.  So many people, in fact, that nobody knew who was in charge and except for ordering more and more tests nobody did anything.  The NEJM article sites the “Bystander Effect” which is the tendency for everyone in a big group to assume someone else will act.  Finally, the patient was saved by an acute problem which forced a doctor on the spot to actually do something.

Quality care is doing the right thing at the right time.  On both counts the NEJM case represents low quality.  Other factors beside the “Bystander Effect” may have been at work.  Perhaps the “Silo Effect” where all the care givers were in their own silo without regard to the big picture.  Perhaps it was the “Swiss Cheese Effect” where  errors on several levels lined up and the patient fell through.  But, most likely, the low quality was due to poor communication — the usual suspect.  If the care team does not talk the sense of urgency and the sense of danger are lost.  The patient was in grave danger!

So, you think this would never happen to you or happen at your local hospital? Think again.  It happens all the time when more than one doctor is involved (including on-call doctors).   Are there solutions?  Yes.  The most desperate need is always to designate who is in charge for every minute and every hour and every shift — including doctors and nurses.  In-charge is not a title, it means willing and able to act.  There should be a sign in each patient’s room with the name of the in-charge doctor and in-charge nurse.  Also, there should be a sign on the intensive care door: “All consultants who enter must talk to the doctor  in-charge before leaving”.

On a more hopeful note, research has some useful  ideas  for the teamwork-challenged hospital.   Here are some pre- and post-shift check lists from the STEPPS program:

Briefing  Checklist

During the brief, the team should address the following questions:
___ Who is on the team?
___ All members understand and agree upon goals?
___ Roles and responsibilities are understood?
___ What is our plan of care?
___ Staff and provider’s availability throughout the shift?
___ Workload among team members?
___  Availability of resources?

Debriefing  Checklist

The team should address the following questions during a debrief:
___ Communication clear?
___ Roles and responsibilities understood?
___  Situation awareness maintained?
___  Workload distribution equitable?
___ Task assistance requested or offered?
___  Were errors made or avoided? Availability of resources?
___ What went well, what should change, what should improve?

The question of  “who is in charge” is critical for hospital care.  Trauma surgeons seem to have this issue mastered (they are in charge) but other doctors are in a quandry when more than one is involved.  Patient safety demands US hospitals do better!

Finally, a comment about cost.  The lack of someone in-charge leads to high cost.  The NEJM article itself failed to mention the cost of 40 doctors working on the case.  In this time of rising health care cost the nation can not afford such lavish use of resources.

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S is for Specialist


An expert is someone who has succeeded in making decisions and judgments simpler through knowing what to pay attention to and what to ignore.
(Edward de Bono)


There are about 50 common types of  medical and surgical specialists.  The list runs from allergists to vascular surgeons.  So, in the big picture of health care where do they fit?  Do they add to health care quality?  Are their services cost-effective (as you might evaluate a drug or device)?  When should a patient see a specialist (or not)?  Why are specialists happier than primary care doctors?

Many years ago there were no specialists.  Doctors delivered babies, set broken bones and used leaches.  Treatment of war wounds with amputation heralded surgery as a specialty in the latter part of the 19th century.  As time went by other specialties came into being mostly because specialists were the conduit from research to clinical practice.  As medical information was more widely available specialists simply had more experience with uncommon or difficult problems.  Specialists led the way for new treatments .  Pulmonary doctors treated consumption (TB).  Cardiologists studied EKGs.  Obstetric specialists invented forceps for difficult births.  Now there are at least 50 varieties of specialists.

The specialist world is divided between procedural (surgical) and medical (expert advice) specialists.  A cardiac surgeon is a good example of a surgical specialist.  An endocrinologist is a good example of a medical specialist.  Some specialists do a little of both like cardiologists who do heart catheterization procedures and provide expert advice for treatment of heart disease.  Medical research has exploded to such an extent specialists still maintain an edge by focusing on smaller and smaller areas of expertise.

One might be led to believe every condition should be evaluated by a specialist.  But, there is good evidence to the contrary.  Based on Medicare data:  Areas with more specialists spend more on health care for Medicare beneficiaries but see no improvement in the quality of care, mortality, or patient satisfaction.  The foundation of modern American medical care is being questioned.  What went wrong?  Is it Kryptonite?  How can this be?

 

There are two answers to what went wrong.  First, knowledge about a disease does not always lead to cure but always runs up the bill for tests.  Second, medication and surgery do have complications that can be serious to the point of shortening a person’s life.  In aggregate the specialty world “hit the wall”.  The positives could not offset the negatives.

The foregoing indictment of specialists really put the wind to the sails of primary care.  In fact, treatment of most common ailments is well established with what are called “evidence based guidelines”.   Quality, safety, cost-effectiveness, and patient satisfaction thus depend on a good process to implement the known guidelines rather than special knowledge.  Until recently primary care providers had the lowest job satisfaction of any provider group.  Now, with a new sense of importance and purpose they seem to be personally happier.

The specialty world is fighting back by addressing cost-effectiveness.  Cardiologists have devised cost-effective strategies for treatment of heart attacks (evidence based guidelines) with dramatic improvement in survival.  Oncologists are following guidelines for treating many cancers and engaging hospice at a more appropriate time.  Gastroenterologists have found they can prevent colon cancers by following evidence based  guidelines for doing colonoscopy.   The world’s specialists are not all on board with the idea of being  cost-effective.  Those who do procedures are still criticized for doing them too often (if you have a hammer everything looks like a nail).

THE BOTTOM LINE:

  1. If you have health problems then have regular visits with a primary care provider.  They usually do have good advice about going to specialists.
  2. Do your homework.  Search the Internet about your problem.  If there are ideas you find then discuss them with your primary care provider.
  3. There is still some “ego” challenge for a primary care provider to ask for help in difficult situations.  The simple question: “Do you think a specialist could help us with this problem?” is usually well received.
  4. If you have a life altering problem or are hospitalized more than once for  the same disease a visit to a specialist is certainly reasonable.
  5. If you do go to a specialist make it clear you want your primary care provider kept informed.  Likewise, make sure the primary care provider communicates with the specialist (sends periodic updates) and follows the recommendations primary care actually  requested.

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