Posts Tagged medicine
Snowbirds: watch out for high medical costs in Florida, Texas, Arizona and California. According to Elisabeth Rosenthal in the New York Times 2/1/15 “Patients Find Winter Havens Push Costs Up”. She points out providers in Florida are the worst offenders — the same place notorious for Medicare fraud!
Ms. Rosenthal highlights one patient from New York wintering in Florida who had a checkup for his pacemaker but did not have any new symptoms. Many in-office tests were ordered by the substitute cardiologist — tests the patient’s regular cardiologist said were unnecessary.
To be very blunt: cardiologists, and other providers, who order in-office tests make a lot of money from those tests. Many studies show providers who profit from tests do more tests than providers who don’t profit from tests. A medical license is not a license to take advantage of patients or Medicare — profit motivation seems to blind some providers to this distinction.
The lure of profit is made greater by a patient not having any new symptoms, not having any record of previous tests, and not having plans for follow-up visits. It is like the patient has a sticker pinned on their back: “TEST ME”. The choice for the cardiologist is simple: either pay the nurse to spend time getting out-of-town records OR make money by repeating tests. Make money, right!
- If you are on vacation and have a sudden health problem your best bet is an urgent care center. They can send you to a specialist, if needed.
- If you have health problems and will be spending several weeks or months away from home:
- Talk to you primary care provider: they may want you to call in and give a report on the phone (diabetes is a good example). If so, no office visit may be needed while away.
- Get enough medication to last the trip. Or, get prescriptions with refills at WalMart or Target and have the prescription transferred to a store near your winter location.
- Identify a doctor to see in your vacation area before you leave. Ask friends or other people who winter in the area for a recommendation. Call the distant provider office and get a FAX number so records can be sent.
- If your primary care provider thinks you need a health care visit while you are away then make an appointment and have your records sent before you leave home — also take a paper copy!
- If tests or surgery are recommended then call your regular doctor’s office to see if they agree.
- Give any provider you see your regular provider’s name, address, phone number and FAX number (a business card is good). Request that results of visits, tests or hospitalizations be faxed or sent to them — and make sure it happens. Fill out a release of information form while you are at the office or other facility.
Nancy Morden MD MPH with others from the Dartmouth Institute for Health Policy and Clinical Practice published a nice “Perspective” in NEJM 3694;4:299-302. The essence of the article is the observation that published goals of treatment which don’t specify how to reach the goal lead to prescribers” jumping the gun” with strong expensive medications rather than a prudent step by step approach.
A good example from the article is controlling blood pressure. Guidelines state the desired blood pressure goal is less than 140/90. Prescribers tend to skip dietary management, skip lowering the salt intake, skip reducing alcohol consumption and jump right to strong blood pressure medications (with the attendant drug allergies, risks and costs).
Another criticism is stopping a medication too soon. The example is beta-blocker medication after a heart attack. It is not enough just to start the medication. The medication must be continued indefinitely. Too often the medication is stopped because the reason for starting it is forgotten.
Here are the areas the authors found problematic:
- Blood pressure control
- Cholesterol management
- Diabetes control
- Clot prevention for occlusive vascular disease
- Lipid control for coronary artery disease
- Long term beta-blocker after heart attack
- Avoidance of antibiotics for acute bronchitis
- Drug use generally in the elderly
From the patient standpoint: if a health care provider says you have some condition or diagnosis make sure to ask for a step-wise approach to treatment. In other words, ask for simple or less expensive things to be tried first. Then insist on follow-up to see if the first steps work. If the simple things work, you win. Make sure to research the diagnosis on the internet to exhaust the simple and low cost alternatives. Later, if the simple things are not enough move on to the next step.
There are obviously situations where a slow cautious approach is not correct. If you are having a heart attack or a stroke or a blood clot it’s too late to do simple things.
Make sure to understand how long a medication might be needed — if it is “until something better is found” then stick to it and make sure the providers give a good reason for stopping (particularly if you change providers).
This clinic has a pharmacist on staff to discuss medication issues with patients. And, that pharmacist calls all new patients to review ongoing medications, record them in the medical record and make recommendations that the new doctor will review at the upcoming visit. Recommendations like problems with drug interactions, newly available generics, less expensive alternatives and contraindications.
That same pharmacist arranges refills and responds to drug questions on the clinic Internet Portal.
What a great service. Discussion of medications by physicians is usually too brief. And, any input from the pharmacist is usually after the fact so physicians are not too happy to call the patient and admit a problem with prescriptions they just wrote.
Sometimes great ideas just need a SHOUT-OUT. This idea is super — an actual partnership between a prescriber and a pharmacist.
Today’s lead story in the New York Times (3/31/13) is about the sad result of a dangerous chemical used by workers to make cushions for furniture. The chemical is n-propyl bromide (n-PB), a spray adhesive to stick urethane cushions together. Click this link to see an n-Propyl Bromide materials safety data sheet (MSDS). The workers were exposed to the chemical and suffered long-term neurotoxicity manifest by difficulty walking and using the hands. The workers were clearly hurt and there is a lot of finger-pointing at the management and the US Occupational Health and Safety Administration.
A true story with a better outcome follows:
A man started his own home insulation business and learned how to spray foam insulation. He was young and very fast so he decided he could apply the foam and get out of a room so quickly protective gear was not needed. He hired several other workers for his small company. Time went by and he developed cough, wheezing and shortness of breath always worse after a day on the job. His wife insisted on a visit to a lung specialist who told him he had occupational asthma from the spray and must NEVER use the substance again. He stopped using the spray and immediately purchased safety equipment for his workers. The company owner commented: “wow, that’s bad stuff”.
The difference between the two stories illustrates important points:
- If the owner of a company develops a health problem from occupational exposure the doctor is not questioned and immediate corrective action is taken. The scenario is called the “pilot’s incentive”. Pilots are very willing to fix airplane safety problems since a crash might kill them. But, business owners divorced from the health risk and concerned about how much the corrective action would cost do not act quickly.
- Workers often seek help from local physicians. The physicians are afraid of getting drawn into a suit. And, as in this case, if the MSDS does not explicitly list the health problem no action is taken. Doctors avoid chemical related workman’s compensation because of the paperwork and legal obstacles involved. MSDS sheets must be updated every 3 years. However, there is no mandate to perform research to actually add to the basic information — and it seems foreign safety data is not well accepted.
- Knowledge of occupational-exposure risk often does not deter workers. For example, in the late 19th century miners knew the risk of death from using the steam driven hammer called the “widow maker”. The miners died in their 20’s from breathing rock dust, a disease later named silicosis. But, they took the jobs anyway because the pay was good. The pay at the furniture factory was $10/hour, perhaps that was the best pay available. Workers were aware of co-workers getting sick but they worked on and on despite difficulty breathing and difficulty walking.
- Workman’s compensation insurance is required in every US State. If an injury is caused by something at the workplace the worker usually gets monetary compensation. And, the compensation is tax free.
Here are some simple suggestions:
- If you have a health problem make sure to tell your doctor about your work environment and any exposure to fumes, dust, chemicals and radiation. Bring copies of the MSDS sheets appropriate to your job (employers are required to have a file of this information).
- If other people at the job site are having similar health issues the job may be the cause — no matter what the MSDS says.
- If a workplace health problem is suspected see an occupational medicine specialist. Your local health care provider may be knowledgeable but may be easily overwhelmed by the amount of uncompensated time it takes to resolve the issue.
- There are other jobs, other cities, and other states — disability and death can never be fully compensated so don’t risk your health for a job.
An Interim Report from the Institute of Medicine (IOM) about geographic variations in care was just released. This is a very scholarly report with massive statistical analysis. The basic idea was to review what Medicare paid for various types of medical care, devices and drugs across the US to see if some pattern could be identified. The hope was to find some way to alter the payment scheme to improve the value of health care. Alas, they could not find a pattern, only wild variation. An individual doctor might be cost-effective for one disease and a money-waster in another, doctors within a group would range from judicious to wildly profit-motivated and the variations between hospital referral areas show the same scatter.
The holes in the target above are an example of wide variation. The archers did not hit the bulls-eye very often — there is a lot of variation. A particularly interesting graph from the report is redrawn above on the right. This is about how often gastroenterologists in an unnamed state perform a stomach scope (EGD) with the billing diagnosis of heartburn (i.e. gastroesophageal re-flux) .
The vertical axis is the number of EGD procedures per 100 diagnoses of heartburn (the procedure rate). The horizontal axis is the ordered list of 403 gastroenterologists in the state. The list is in order of the lowest to highest rate of performing EGD. The ovals placed on the s-shaped curve represent 17 different doctors all in the same group. The remainder of the 403 gastroenterologists are plotted as dots on the curve. If all the gastroenterologists approached heartburn in a consistent and reliable manner the graph would just be a horizontal line somewhere in the lower part of the graph. Instead we see some gastroenterologists performing a scope on 100% of people they see who have heartburn — to be clear, this is the picture of unnecessary procedures or “padding” the bill.
What does it mean?
Gastroenterologists are poor marksmen. No, no, no. It means they are shooting at different targets. Some aim to maximize revenue, some aim to follow evidence based (lower cost) guidelines and some aim in-between. Keep in mind that a gastroenterologist is paid about $200/hour for clinic visits and about $1000/hour when doing procedures. The doctors on the right side of the graph clearly have targeted the high paying procedures “scope first and ask questions later!”
The IOM claims no insight into the mysterious variation. It is not necessary to study this more! Look at other countries, they don’t have this problem because other countries don’t pay doctors by the number of procedures performed. Simply pay the gastorenterologist the same hourly wage for seeing patients in the clinic as doing a procedure. In the big picture, the variation can be markedly reduced by having doctors employed by an accountable care organization (ACO). The ACO sets the salary, pays the malpractice insurance and provides the office to practice — a doctor in an ACO just has to focus on doing what is right for the patient, not what is most profitable for the gastroenterologist.
What should be done?
Although the graph puts gastroenterologists in the spot light the data show the same scatter across the spectrum of doctors. US health care is sliding more and more into the swamp of poor quality and high cost. The US needs doctors to aim for the right target and to aim for reliability, which means to consistently hit the bulls-eye. Hopefully the IOM will have the strength to recommend strong action to change the whole system of payment for US doctors, hospitals, drug companies and equipment manufacturers. Instead of trying to make a perfect system we need a good system that can be adjusted as needed to achieve both high quality AND low cost care.
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.
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?
- If this is a refill the pill should look the same as before
- 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.
- Look at the medication bottles and verify
- 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.
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!
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.
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.
One winter afternoon Mr. C was at his health club enjoying a workout on the StairMaster. Suddenly, he began to have a nosebleed. In the past, any nosebleed would go away with some pressure but this was different, the bleeding just would not stop. Driving his car was out of the question. Fortunately, another health club member offered him a ride to the ER. On the way they passed an urgent care clinic but did not stop. They were concerned the urgent care clinic might not be able to stop a nosebleed. The towel he used to catch blood was getting very red and he was a little frightened by the thought of bleeding to death.
Holding his nose with the towel he checked in to the ER and was quickly taken to an ER room. After 20 minutes a nurse evaluated him and took his blood pressure. His nose continued to bleed and 30 minutes later a doctor arrived. He put drops of epinephrine in the nose followed by a nasal pack. The bleeding stopped, he was given an antibiotic pill (ciprofloxacin), he rested a few minutes then his wife took him home. A few days later his wife removed the packing as directed. Problem solved — at least the bleeding problem.
He eventually got a statement from his Medicare (MC) supplemental insurance company.
|epinephrine 4 drops||$204.60||$0 *||$204.60|
|ciprofloxacin 500mg||$50.82||$0 *||$50.82|
* Medicare would not cover (“allow”) the medication because the medication was categorized as an outpatient charge. What Medicare does not allow supplemental insurance will not allow either. So, the patient has to pay.
Wholesale prices of medications are as follows:
epinephrine 1 mg/ml (0.1%) 1 ml ampule $2.55 (charged 80 x cost)
ciprofloxacin 250 mg 2 tablets $0.45 (charged 110 x cost)
See the reference on nosebleeds (epistaxis).
Could there have been another way? Less waiting and less cost? Perhaps. Consider the following alternative scenario:
A patient had a nose bleed for 5 minutes at which point he called his on-call primary care provider (PCP). The patient was instructed to go to an urgent care center. Waiting was minimal since bleeding is a big deal at the urgent care center (at the ER there are bigger things going on). The treatment at the urgent care center was the same as the ER except a prescription for ciprofloxacin was given to him which he picked up at the 24 hour pharmacy ($0.50). The charges and out of pocket expenses for the urgent care visit were as follows:
|epinephrine nasal||$20 (est)||$0||$20.00|
It is important to note there is no “facility” charge at the urgent care. Only hospitals can charge for use of the facility. Ostensibly, this is to offset the costs of maintaining higher staff levels to be ready for really big emergencies. In effect, by going to the hospital ER the patients with minor problems subsidize the patients with major problems.
The bottom line: At your next visit with your PCP discuss how they want you to handle minor and major emergencies. In general, if you feel you have time, call your PCP’s office (even at night because someone is on call) before going to the emergency room. Use urgent care centers rather than the ER if possible. Don’t accept a facility dispensed medication to take at home if there is a nearby 24 hour pharmacy. If your PCP is aware of an urgent problem they will likely follow up when needed.
Laura Landro of the Wall Street Journal reported on a growing trend in US hospitals. The trend is the “Observation Unit”. In hockey terms it is the penalty box where hospitals put patients they can’t send home but can’t admit, at least for a few hours.
The origin of this idea may have come from English hospitals. Those hospitals run at almost 100% occupancy. So, when a patient from the ER needs to be admitted there is a delay to wait for a room. Those patients get put in a big room next to the ER with several gurneys, a few nurses, and lots of curtains (the observation unit). The patients do get tests and treatments but they wait for a room. As it turns out, some of the patients get better and don’t actually get admitted — they go home — the rest eventually go to a hospital room. In England hospital care is free and the hospitals don’t have to worry about insurance or Medicare rules that separate outpatient and inpatient charges.
US hospitals have plenty of beds available but US hospitals do have to worry about insurance and Medicare rules. Care is not free and if a hospital makes a mistake (like admitting for indigestion) they don’t get paid. And, if a doctor makes a mistake and sends a patient home who should have been admitted (for a heart attack) they could be in legal trouble. Consequently, unlike the English hospital that needs to hold patients to wait for a bed the US hospitals need to hold patients because of red tape and legal worries! It’s hard to tell which is worse.
The Wall Street Journal article puts a positive spin on the “new” idea: “when operated efficiently observation units have been shown to reduce health-care costs and improve treatment”. Obviously there is a balance of forces between the Hospital that makes money and the insurance company that looses money with each admission. Regulators try to develop rules to speed evaluation and treatment so some patients can go home safely without a hospital admission and the huge associated costs. Any patient who can bypass the hospital will also avoid the risk of hospital errors and exposure to hospital acquired infections.
Patients have two main concerns:
1) Getting the right care the first time and not coming back sick. The unit may provide a little longer time to get test results and see if treatment is working which is good unless unnecessary tests are being done.
2) Minimizing out of pocket cost. A person without insurance would get a lower bill by avoiding the hospital but having both the cost of observation and hospitalization is a real possibility. The current trend for insurance is to shift a higher percent of outpatient charges to the patient compared to inpatient charges. So, depending on what a person’s insurance covers, there might be higher out of pocket expense for using observation.
The following is extracted from data presented by the Dartmouth Atlas.
Data about high ranking academic medical centers is plotted above. On the vertical axis is the patients rating of their experience at the hospital — the higher the percent the better. On the horizontal is the rate of a severe infection complication of tubes put in the veins (which should be taken out periodically) — the lower the rate the better. The hospitals in the lower right have the highest rate of undesirable “line” infections AND the lowest rating by patients. The hospitals in the upper left have the lowest rate of such infections AND the highest satisfaction.
The point is: the hospitals are all over the map (poor reliability). Worse yet, patients seemed to give some hospitals high marks for poor performance. To be fair, very few patients actually get line infections so the negative effect on overall satisfaction is small. It would be interesting to evaluate satisfaction of patients who had line infections (if they survive).
So, you say, hospitals need to work harder. That would be true but where are the guidelines for removing these problematic vascular catheters? The CDC and others describe how to care for the catheters but leave it to “judgement” when to take them out. The problem is “judgement” is not conducive to reliability.
Make a rule and follow the rule! Sure there are exceptions, like it’s the last vein the patient has — judgement is when you state why you are not following the rule. The specter of malpractice litigation is here. Although the rule of law is doctors are not held responsible for a well considered judgement (which later may prove to be wrong) it often does not work that way in court. So, a good defense would be that a national guideline was followed — if it existed.