A whole new way to "cut" Costs

So it's come to this has it? Instead of cutting costs we are just going to give a whole new meaning to the word "cut". We can't seem to get those mean old drug companies to lower their costs (I mean we asked them nicely and all they said was "haven't you seen all the great charity work we do?") so instead we are doing a different kind of cutting. Several insurance companies including the giant United healthcare are advising their patients to cut pills so they can stretch the doses and make their pills last longer (article attached). This is wrong on so many levels that I can hardly stand it. My mind is running wild with things to say (like what about the dose the doctor prescribed?) so let's just start with the most obvious question. Why are we not acting like customers to these drug companies and telling them that either they cut their costs or we aren't going to take their damn pills! We act as if we forgot how to be consumers. If something costs too much then you switch pills, demand a lower cost, use your buying power to force a lower price or something like that. (I know you can't always switch pills but in many cases you can) Instead we act as if we are just a scared bunch of puppies with no recourse whatsoever and we sheepishly cut our pills as if that will solve anything. Where are the pitchforks? Wheres the indignation? Where are the organized marches? Stand up people and demand a better cost. Don't demand it from your politician or your insurance company or your doctor or your mother........demand it from the drug company. They are the makers of the pills, they make them very cheaply (despite their claims of outrageous R&D costs), they set their prices to get the most they can from the insurance companies and they are the ones that can lower them. It's not that tough...ok, it is tough but only because we have forgotten who the real culprit is. In health care the blame is deflected every time you ask. You are correct if you are thinking the insurance companies should be getting these costs lowered but as you can see they are either not interested or incapable because they are making a fortune as well. Consumers are truly on their own in health care because the insurance company blames the drug company, the drug company blames the doctor, the doctor blames the hospital and the hospital blames the patient. So there you go it's back to you, the patient, and I say that you blame the proper entity and in this case the drug companies are that entity. Lets focus our indignation on them and quit cutting pills in our pantries.

Medicare Can't Control Costs Either?

A very large and very depressing study was just published in JAMA (Journal of the American Medical Association) that failed to show cost control with aggressive treatment of the sick and elderly. Basically, Medicare tried to show that costs would be lower and hospitalizations less if they were more aggressive and the results were.....well, horrible. Costs were higher and people were still just as sick. This is truly frustrating to hear and yet it comes as no surprise at all. When you take a bureaucratic and bloated system that is outrageously expensive on all levels and try to prove more of that same system can do better you might just find out that mom was right when she said "the definition of ignorance is doing the same thing twice and expecting a different outcome". Okay maybe that wasn't the exact quote and maybe it wasn't your mom that said it but you get the point. We have been going down this same path in the US for over 50 years now trying to modify and tweak and change the system for the better and nothing has worked. An abridged list would include medicare, medicaid, HMO's, PPO's, HSA's, TPA's, QA, IPA's, MSA's, and many more which I will spare you the effort of reading. All of these efforts have had one uniting factor and that is that in retrospect none of them did anything to control costs. I am almost tired of hearing myself say (and just be glad you don't have to live in my head too) that until you control costs, you won't solve any part of our current health care crisis. All of the pointy headed intellectuals who attempt to change health care always talk about patient responsibility and consumer oriented health care and fancy terms like that. That's great and I am sure it gets them hired to stand at a lectern and tell everyone their thoughts for curing the health care system but there is a slight problem. We are going bankrupt and spending nearly $2.5 trillion dollars a year on health care! Even people with health insurance are going bankrupt when they get a serious health issue like cancer!! I am putting more exclamation points with each sentence and people still aren't getting it!!! I don't know when we will learn the lesson of cost control but until we do all of these other efforts will fail. Let's quit dancing around that subject and then we will start to see some real benefit from our efforts.
Other than that, I don't really have an opinion!!

So What do the Candidates Think?

Now here is a challenge: Talk about health care and get people excited to read it while at the same time weaving politics into the mix. I have been meaning to discuss the upcoming presidential elections with regards to the two candidates and their positions and for some reason the excitement level just wasn’t there. I would start the article and then scrap it because even I was falling asleep and if the author falls asleep during an article what chance does the reader have? I mean just the title “health care politics” dredges up thoughts of long boring meetings and lectures you never wanted to hear. But maybe we can make it fun so lets give it a go. Unless you have no political interest at all I imagine you know by now that we are finally down to two candidates running for office since the primary season is over. (I should hasten to add that I frankly want the whole lot of them gone so I am voting third party this year just to stage my own little protest so in actuality there are still more than two candidates.) For purposes of this little blog we will discuss the main two positions, which shouldn’t take long. Yes I am qualified to do this because I have actually read the plans that each of the senators has on their individual websites so you should be thanking me for the work I have slaved over for you. I didn’t simply take the summaries put out by the media so you should be proud of me. Just because I had a beer to help me through does not diminish the significance of what I have done. So let’s start with Senator Obama and his plan. I can sum it up real quick by telling you that he is going to mandate coverage to all and in so doing he will lower the cost of health care. If people can’t afford the insanely expensive cost of health insurance then taxpayers will pay for it – hardly a cost saving method there. Kudos to Obama for finally getting the uninsured covered but what makes the Obama campaign think that will lower the cost of health care? He explains it in many ways but to summarize his plan it only increases the oversight (ie-bureaucracy) and will do nothing to actually decrease the cost of health care. Just saying it will does not make it so. Health care is the poster child of unintended consequences and when you cover everybody it is historically accurate to say that will increase the prices that doctors, hospitals and drug companies charge. Where is the cost savings in that? So Obama’s plan is bad but not near as bad as McCains. The only thing even remotely unique or different about McCain’s plan is that he says he will allow health care to be bought across state lines and that can hardly be considered thinking outside the box. In a sector of the economy that will ultimately bankrupt this country unless changes are made, McCain essentially says “hey, working good from where I sit so let’s keep it the same”. At the risk of sounding like a long-suffering nanny, that is a “poor choice”. Lets be blunt. The only fact on the health care dilemma that all parties agree on is that health care is too expensive. In other words it costs too much and that means sticker shock when you go to the hospital, doctor or pharmacy. Since we all agree that health care costs too much then I propose that unless a policy helps to bring down the cost of health care……don’t do it! Increasing oversight in health care and subsidizing outrageous insurance bills (Obama) or attempting to convince us that keeping things the same (McCain) in an unsustainable health care system are what I consider outrageously ignorant solutions and are nowhere near the vast changes we need to implement. That, my friends, is one of many reasons why I will be voting third party this year.

Stop the Insanity!

Remember the lady 10-20 years ago who created a diet fad around the idea that diets don't work and she would always yell out "stop the insanity!" to the point of driving you insane? If I remember right, Susan Powter was her name. Well, I want to start yelling that at the health care industry for some of their useless studies because it seems like every week I see another study that comes out that makes you say in a very mature manner "well, duhhhh.....I could have told you that myself and saved you a couple million dollars".
Last week I heard of a study that related the increased risk of stroke in women to the fact that they visit the salon more and tilt back their head a lot thus increasing the pressure to their carotid arteries which induces damaged plaque to break off and travel into the brain which creates a stroke. Thats a little bit like performing a study on drivers that found that unsafe drivers were the ones who had peanut butter for breakfast because their tongue was stuck to the roof of their mouth and they were searching for gum so they ran into a telephone pole. To sum it up: Subjective, Stupid and pure conjecture. In no way can that be proven and even if it were then what do you propose as the solution? Having women wear neck braces at the salon so as to protect their carotid arteries. Wouldn't that create even more deaths from choking? It seems we have a dilemma.
In my particlar specialty there was once a study done that measured toenail growth (I kid you not) in the summer as compared to the winter to determine the specific time of year when toenails grow the fastest. I would like to see the conversation that led to that study......Ok maybe I wouldn't. I can't even imagine how bored you would have to be at work one day to decide "wow, I really have no idea whether toenails grow faster in July or December and I have no idea how I have run my practice to this point without that information!". So you launch the life saving study for which society will forever be indebted to you.
This week's choice of stupid study though is not quite so obvious but dumb nevertheless. A study published in the journal Neurology found a link between belly fat in your 40's and dementia in your 80s. Dementia for those of you who may have "forgotten" is the condition where you lose short term memory and eventually fade into more permanent memory loss which is a very frightening idea for all of us. Well this does seem like a reasonable study though because we all want to know how to avoid dementia so that we don't forget how (to avoid it that is). The problem is applicability (ie-what do we do about it?) and the definition of belly fat. See, as a bit of perspective our current view of fat is that it only takes second place to terrorism in public safety and pure evil....Ok fine I am sure cigarettes are in there somewhere near the top as well. So this study decided that people who store fat in their abdomen (and for the record everyone does even if they are skinny) had a higher risk of developing dementia. In other words, we all have a higher risk of developing dementia while we are alive. I guess we could have saved a lot of money on that one and just come out and said "as long as you are alive and not dying of starvation you are at risk of dementia and dying". That would have summed it up just fine but then it wouldn't accomplish the agenda some people seem to have of saving us from ourselves. I don't know about you but I can't wait for the study that comes our to determine whether we are more at risk for death the longer we live. Now that would be some useful information.

Ahhhh, Pharmucopia at Last!

When former Colorado governor Dick Lamm joked in his recent book (A Brave New World of Healthcare) that by 2066 we will spend 100% of our GDP on Healthcare I began to wonder what that world would look like. Would we take pills for food? Will we all have a permanent IV implant that would constantly feed and nourish our every need through a venous portal? What about work? I guess we would all work for a health care company or not at all and as a doctor I guess my future would be pretty secure. Maybe vaccines would take care of everything since we seem to be vaccinating all sorts of ailments from polio to the common cold. Whatever the future looks like in this scenario I was fairly sure I didn't want to be a part of it. Until recently that is.

A new report came out this week on a recent study of our water supply that shows all sorts of drugs floating around in our water from antipsychotics to sex hormones. A virtual pharmucopia. This started to bring the picture into a little more clarity and it really doesn't sound so bad now. Pharmaceutical companies obviously know what is best for us and they have been told incessantly how difficult it is to swallow their horse pills so they are coming up with the perfect solution. Put the pills in the water supply. I knew I had felt better lately and in my naivete I had given the credit to my wife who had recently placed me on a vitamin drink. How simple of me. Clearly the pills in the water supply are taking care of my every need from constipation to diarrhea and everything in between. The antibiotics keep me healthy from infection. The antidepressants keep me happy. There are even anti-convulsants in there in case my brain should decide to give me a seizure. These brilliant pharmaceutical phriends have thought of everything! And I had the audacity to doubt them. I want to take this opportunity to apologize to all pharmaceutical companies and reps who come into my office because clearly they they do know what is best for me and my patients. I don't even dread the future any more and I think a world of all health care is starting to look pretty good......in fact I am starting to get sleepy. In the end it is nice to know that when our politicians say they want "universal health care" that the drug comanies take them literally. Cradle to grave baby. Your wish is their command.

I hate to say I told you so but....

It seems to me that a pattern is developing here. We cover things (like medications, etc.), drug companies raise their prices and costs escalate. Pretty simple formula. If you are a drug company and someone else is paying for a patients drugs (like an insurance company or Medicare) then you could raise your prices without anyone getting too upset. In fact, it is pretty logical to think that you could raise your prices much easier in that scenario than if someone was paying for your product directly. Am I missing something here?

In 2005, Congress and the Bush Administration created Medicare "part D" which was a reasonable idea given the fact that medication costs were soaring and threatening to bankrupt many of the elderly. The problem at the time was that the law specifically forbids Medicare from negotiating in bulk with pharmaceutical companies thus limiting the overall negotiating pressure that Medicare could exert on prices. So guess what happens. In 2007 brand name drugs (non-generic medications) rose 2.5 times the rate of inflation and (here is the real shocker) there was an overall 7.4% increase in the wholesale price of brand name medications in 2007 compared with a still significant but smaller raise of 5.3 to 6.6% in the four years prior to Medicare part D implementation. In plain English that means that every year drug companies raise their prices an outrageous amount but since part D started this has allowed them to raise their prices more. Medicare is paying for them (except that in reality seniors still have to foot a large portion of the bill-and even more as price increases are implemented) so now the price increases go largely unnoticed. Now the cycle that I raised above becomes clear and you have to ask yourself a fundamental question, "who really benefits here?". I think that answer is fairly obvious but in case I confused you with this blog (since it is 2 am) let me just assure you there is only one winner in this scenario and that is the drug companies.

Prior to the Medicare bill being passed, the Bush administration formally estimated the 10 year cost for the bill to be somewhere around $350 billion. After the bill was passed, the Bush administration admitted the cost of the bill was miscalculated and would cost somewhere in the neighborhood of $750 billion which appears to be a fairly significant miscalculation but I am sure I am too critical. At the time I said I would bet a nickle that the cost would run over $1 trillion for the 10 year period and even though I do not want to be right in this prediction it looks like I probably will be. Oddly enough, it appears that patterns do repeat themselves and I now know what my parents meant when they said that "those who don't learn from mistakes are doomed to repeat them". When are we going to learn that covering things without regard to how much they cost will ultimately bankrupt us in the process.

Health Insurance Lottery

In a never ending stream of information that is proof that health care is too expensive for the average citizen, my home state of Oregon has now established a lottery for health care that gives the lucky recipient a chance to avoid bankruptcy by attaining coverage that they otherwise have no chance to afford. This is a sad day when we reach a point where getting health coverage is equivalent to winning millions. In a day and age when health costs demand "your money or your life!" it is no wonder that getting health care coverage would be the prize of a lottery system.
An interesting statement has come out of this. According to Barney Speight (director, Oregon Health Plan Fund) the state of Oregon has a comparable number of uninsured right now as they had in the late eighties when the last effort to "fix" heatlh care was implemented. This is an absolute confirmation that we cannot fix this problem unless we do something to address the underlying cost issues because even if states could cover their uninsured patients somehow the problem would still return 20 years later in a much worse scenario because health care costs continue to eat into our overall GDP. I know that is a bit technical but this is why we say the health care crisis is about "cost not coverage".
Good for Oregon for thinking outside the box (as they have on many past issues) but if you ask me this is a pathetic statement on the sustainability of health care costs bound to bankrupt us all eventually.