An interesting proposal

The Universal Cure – clearly a very interesting proposal and relevant to our previous discussions. What do you think?

Relman’s op-ed

Your Doctor’s Drug Problem written by Arnold Relman – former editor of the New England Journal of Medicine.

Relman identifies the problem of drug company controlled CME, but overextrapolates the evil.

To renew their licenses, doctors in almost all states are required to enroll in continuing medical education programs, and these are now largely subsidized, directly or indirectly, by the pharmaceutical industry. There are official guidelines for keeping these programs free of commercial bias, but they are voluntary. Most of these educational programs are presented by industry-friendly experts who are selected and paid by the companies selling the drugs being discussed, and most of their talks emphasize the medical benefits of those drugs. Some of this information is useful, but much of it is simply marketing disguised as education.

Let us clearly understsand the problem. Often drug companies will sponsor a speaker on a topic. The speaker will talk about an issue relevant to the company’s drug. Some talks almost blatantly cheerlead for a particular drug. Other talks just increase awareness of the entity that the drug treats.

There are multiple levels of hell. We can modify our current system to disallow the most egregious talks, while preserving the true contributions.

I agree that we have a problem. I disagree with the extent of that problem. I disagree with Relman’s assertion

So it is not merely that the pharmaceutical industry is using doctors to sell its products. Medical schools and other educational institutions are not teaching doctors how to use drugs wisely and conservatively. Until they insist that the pharmaceutical industry stick to its own business (which can include advertising but not education), we are unlikely to get the help we need from our doctors in controlling runaway drug expenditures.

I hear many talks at medical schools which do teach physicians how to use drugs wisely and conservatively (and I even give some of those talks myself). We have a problem, but many educators are addressing the issue.

So read his op-ed, but try to keep his thoughts into perspective, avoiding the hyperbole.

If I could change everything – further thoughts on Sowell

If you have not read Thomas Sowell’s 3 part essay and the many outstanding comments that this post engendered, go there, read the post, Thomas Sowell and the comments. Then come back to here and I will rant. Thomas Sowell – no free lunch medicine

Welcome back! We clearly have a health care crisis in this country. Let me enumerate my concerns:

• We have great advances in pharmaceuticals, which many patients cannot afford.
• Many patients cannot afford basic care
• Many physicians have significant overhead problems, while having either a fixed or decreasing income per patient visit
• Physicians often act in fear – fear of malpractice.
• Excellent medical care is becoming increasingly complex. This complexity requires physicians to spend more time reading and more time with patients. Yet, our system discourages spending time with patients and time reading.
• Our system does not fit a free market system as patients are divorced from financial medical decision making (the insurance companies have abrogated that responsibility). Moreover, the physician generally has little control over revenue per patient (again the insurance companies and in particular the government have that responsibility).

That admittedly short list provides a foundation for my frustrations. Let me first state that I love medicine and being a physician. I would highly recommend this profession to any one who asks. That does not mean that we cannot improve our current crisis.

Thomas Sowell argues for a free market approach to medical care. I agree. However, I probably disagree with him on this fundamental assumption – we are far from living in a free market system today. We are beset by bureaucracy and poor laws. Let me try to explicate.

I favor medical savings accounts for most medical care (rather than insurance). Medical savings accounts would encourage patients to ask questions about prices. With insurance and a drug benefit, the patient might want Nexium (the evil purple pill). If that same patient were paying from a medical savings account he/she might choose Prilosec OTC (for approximately 20% of the cost).

We should combine this with a new method of billing for outpatient care. We should be billing for time spent with the patient (with everyone understanding that physicians spend significant time on that patient’s care while not physically in the room). Patients would know what a 10 minute appointment costs, what a 20 minute appointment costs, etc. While this billing method has some problems, having the patient actually pay the moneys would minimize abuse of the system. Patients would have an explicit expectation of service from us, and would make reasonable demands on our time (knowing the cost involved).

We need to modify the pharmaceutical laws. We do not need loopholes for drug companies to block generics as their patents expire. They deserve a fair run at profits on an individual drug, then let the marketplace work.

We need to fund more studies comparing 2 or more drugs of a class, and drugs of different classes. These studies (with appropriate publicity of results) would inform patients and physicians – choosing the right drug for the patient.

We need even better post approval studies of side effects. We need to better know the rates of side effects for each drug.

We need free market pricing. Currently we have price controls on physicians and hospitals. We a different system of paying physicians and hospitals, free market forces would control prices. We would have winners and losers. Physicians, who patients perceive provide more value, would be able to charge more. Similarly, hospitals perceived to provide better care might charge more. This system would encourage better care (and therefore more profits).

We need better tax incentives for providing charity care. Many physicians willingly provide a percent of charity care (I would suggest 10 percent as a good start). They would be able to “write off” that care as a charitable donation. I believe this could become a good policy. The same process should work for hospitals. I might even go so far as to demand that all health care providers (physicians, hospitals, clinics) provide a reasonable percentage of charity care. We would also expect a usable system of providing pharmaceuticals and diagnostic testing.

I do understand that I am dreaming. Developing a new system would have too many enemies – insurance companies, perhaps the pharmaceutical industry, perhaps big business. However, our current system is broken.

Some might ask why not universal care? I despise bureaucracy, and bureaucratic decision making. Universal care would bring us bureaucracy. As practiced in most other countries that I have studied, it would lead to rationing. The choices that we would have to make are choices that I would rather not make. They are choices that most of our patients would not want us to make.

I have thought about this issue for the past few days, reading the comments on the previous past carefully, and examining my own philosophy. This rant is not a polished proposal, however, I do stand by the concepts that I have proposed. So bring on the commentary. Attack my ideas. But always refrain from ad hominem attacks on any commentary.

No longer morbidly obese – a reporter’s success

From ‘morbid obesity’ to ‘Wow!’

Bravo!

On palliation

My defining moment came in 1978 during my residency. I was caring for a patient who had aplastic anemia. Because of almost non-existent neutrophils, he was in the medical ICU on strict reverse isolation.

We consulted hematology and they told us that we had no options for treating his neutropenia. (This story precedes bone marrow transplantation.) Hospital epidemiology insisted that he have strict reverse isolation (gowns, masks, gloves) to prevent overwhelming infection. The gentleman (in his 60s if my memory is correct) asked very politely but with great emotion if we could remove the isolation requirement. He told me that he knew that he might die a few days sooner, but he want to see faces, he wanted to hug loved ones, he wanted his last few days to have meaningful interaction with family. He said (and he was right) that the accouterments of reverse isolation decreased his quality of life.

He convinced me and turned on a light bulb. Fortunately I had a wonderful attending who agreed and we overturned the hospital epidemiology decision (to their howling protests). The patient died in a few days, but he died happier and his family was greatly appreciative.

The palliative care movement is (in my opinion) having a major positive impact on many patients and families. They have a new trust in our system of medical care. This piece is just one in a series that I have spotlighted. I will continue to spotlight this issue because it stimulates a positive passion about our ability (as physicians) to make a difference. Providing Care, When the Cure Is Out of Reach