Early Monday morning, I had an office visit with a physician who had a "No Free Lunch" sign prominently posted next to the sliding glass reception window. The notice said that the doctor would not accept free lunch, samples, sales/educational information or other materials from pharmaceutical companies.
Two days later I attended a no-charge all-day continuing medical education program for approximately a thousand physicians, nurses and related professionals, conducted by a national medical education company which has been funded by pharmaceutical companies, an insurer and a local medical society. Subjects included incretin hormones for management of type 2 diabetes, osteoporosis prevention, reducing cardiovascular risk by focusing on HDL, the beneficial blood component, asthma, new Beta blockers for hypertension treatment, fibromyalgia and actinic keratoses/squamous skin cancer. These are all relevant medical subjects and just happen to be conditions for which medications may be prescribed.
While several pharmaceutical companies had tables with representatives, the number was smaller than in previous years. Other than a speaker who (to me suspiciously) grandly extolled the virtues of sitagliptin, the obvious and indirect commercial message was subdued compared to past years. The speakers were professional, competent qualified and (except as described above) appropriately restrained.
And my lunch - half of a plain turkey sandwich, diet coke and an apple. Healthy, but not necessarily "free."
Thursday, November 20, 2008
Sunday, November 16, 2008
Maybe We Can Help The Auto Industry?
It takes a crisis to end our lethargy, a crisis which convinces us that aggressive lifesaving, previously unthinkable, action is needed.
We have our crisis. GM, Ford and Chrysler are moribund, in part, because of crushing health care costs. The Big 3, and its entire American supply chain, is burdened by excessive health care costs, adding to inflation in the price of American automobiles and automobile related services paid by American consumers. America's auto industry is emblematic of our lack of competitiveness in the global economy.
It's time for the multifaceted approach described in my October 10, 2008 blog . Bail out American industry, including but not limited to the auto manufacturers, by giving them a level playing field in global commerce: remove their burden of crushing health care costs by enrolling the entire auto industry's workforce in a plan which is equivalent to that available to Congresspeople, preferably one which has a federal component which (on an even-playing field) competes with major health insurers and systems. Will the public lose? Not if American automakers can sell "green" reasonably priced cars; not if plummeting employment begins to rise again; not if Americans can pay their mortgages and send their kids to college because they are working and optimistic; not when hope is restored to capital markets; not when America is already paying for health care costs which include a 25% wasteful administrative overhead for some insurers; not when millions of Americans have no health care insurance and either don't pay or become public charges; and not when appropriate regulatory oversight of the American automobile production industry is included.
We have a crisis which may soon reach epidemic proportions. We have reasonable solutions at hand which may remediate the health care financial drain on our collapsing economy. Before the patent's eyes close and rigor mortis sets in, let's take action.
We have our crisis. GM, Ford and Chrysler are moribund, in part, because of crushing health care costs. The Big 3, and its entire American supply chain, is burdened by excessive health care costs, adding to inflation in the price of American automobiles and automobile related services paid by American consumers. America's auto industry is emblematic of our lack of competitiveness in the global economy.
It's time for the multifaceted approach described in my October 10, 2008 blog . Bail out American industry, including but not limited to the auto manufacturers, by giving them a level playing field in global commerce: remove their burden of crushing health care costs by enrolling the entire auto industry's workforce in a plan which is equivalent to that available to Congresspeople, preferably one which has a federal component which (on an even-playing field) competes with major health insurers and systems. Will the public lose? Not if American automakers can sell "green" reasonably priced cars; not if plummeting employment begins to rise again; not if Americans can pay their mortgages and send their kids to college because they are working and optimistic; not when hope is restored to capital markets; not when America is already paying for health care costs which include a 25% wasteful administrative overhead for some insurers; not when millions of Americans have no health care insurance and either don't pay or become public charges; and not when appropriate regulatory oversight of the American automobile production industry is included.
We have a crisis which may soon reach epidemic proportions. We have reasonable solutions at hand which may remediate the health care financial drain on our collapsing economy. Before the patent's eyes close and rigor mortis sets in, let's take action.
Tuesday, November 11, 2008
Believe The Brown Journal
Although the New England Journal of Medicine (NEJM) now comes every week by mail without any cover, it used to come in a tan paper wrapper.
One day, as a colleague and I discussed a NEJM article, we discovered that each of us would let the NEJM stack up until the wrappers turned from tan to brown. Then, as with ripe bananas, it would be time to open them and digest the contents. Until the wrapper was brown, there had not been enough scientific scrutiny to trust claims made in the journal's articles.
On Monday November 11, the NEJM article on the use of a particular statin in a "low risk" population with satisfactory cholesterol levels but high CRPs (C-reactive Protein, a marker of inflammation) attracted a great deal of media attention. Experienced physicians will probably wait for several months before letting the article provoke them into prescribing the statin in question for the reasons promoted in the article. By the time the "brown journal" has matured in four or six months, the data will have been scrutinized carefully, appropriate questions will have been asked, biases will have been exposed, the drug company sponsor's biases will have been evaluated, the issue of possible conflicts of interest among the investigators will have been considered, and conflicting medical-scientific questions and issues will have been brought forward.
If you ask most young physicians about the "brown journal" they won't know what you are talking about. If they believe today's news, without paying attention to the information about the study that is still to come, they do you, the patient, no favor. And if you are dubious about my hypothesis, go to any medical library, take a ten year old journal from the shelf, read the drug advertisements, and ask yourself why those drugs disappeared and are no longer used.
One day, as a colleague and I discussed a NEJM article, we discovered that each of us would let the NEJM stack up until the wrappers turned from tan to brown. Then, as with ripe bananas, it would be time to open them and digest the contents. Until the wrapper was brown, there had not been enough scientific scrutiny to trust claims made in the journal's articles.
On Monday November 11, the NEJM article on the use of a particular statin in a "low risk" population with satisfactory cholesterol levels but high CRPs (C-reactive Protein, a marker of inflammation) attracted a great deal of media attention. Experienced physicians will probably wait for several months before letting the article provoke them into prescribing the statin in question for the reasons promoted in the article. By the time the "brown journal" has matured in four or six months, the data will have been scrutinized carefully, appropriate questions will have been asked, biases will have been exposed, the drug company sponsor's biases will have been evaluated, the issue of possible conflicts of interest among the investigators will have been considered, and conflicting medical-scientific questions and issues will have been brought forward.
If you ask most young physicians about the "brown journal" they won't know what you are talking about. If they believe today's news, without paying attention to the information about the study that is still to come, they do you, the patient, no favor. And if you are dubious about my hypothesis, go to any medical library, take a ten year old journal from the shelf, read the drug advertisements, and ask yourself why those drugs disappeared and are no longer used.
Sunday, November 9, 2008
Dear President-Elect Obama
You have staked your political and personal reputation on your promise to reform health care, make it more effective and more cost efficient. My guess is that you have surrounded yourself with experts who tell you that the federal government can save enormous amounts by managing and coordinating disease care for high risk people. These high-cost patients, many of them poor, elderly and not well educated, with multiple diseases, use enormous amounts of government funds for their care. Obviously, your experts will say, spending money on managing disease care through insurers or other plans, telephonically or by personal contact (with such interventions as providing transportation, medication or social service support), makes sense.
As a lawyer and former President of the Harvard Law Review, you know very well that all that is in print is not true, that experts can honestly hold to strong but incorrect opinions, and that one should be skeptical of claims by anyone that he or she has "the" solution. Please use those skills in evaluating the hype about disease management.
The managed disease care solution falls apart under close scrutiny. The Fall, 2008 Health Care Financing Review, in an interesting series of papers growing out of disease management studies conducted by Medicare and Medicaid, shows that savings, if any are negligible. Brown and Peikes (15-Site RAndomized Trial of Coordinated Care in Medicare FFS") found that after two years, the treatment group experienced no gross or net expenditures savings when compared to the control. Esposito and Brown reported that a primarily telephonic patient monitoring and education service "show virtually no overall impacts on hospital or emergency room . . . .use" although for a subset of patients with congestive heart failure program reduced Medicare expenditures by 9.6 percent. In the paper "Evaluation of Medicare Health Support Chronic Disease Pilot Program," Cromwell and McCall's conclusions were consistent with the cited authors' interpretation of their data. Goldfield and McCullough's paper, "Identifying Potentially Preventable Readmissions" unsurprisingly showed that "readmission rates increase with increasing severity of illness and increaasing time between admission and readmission, vary by the type of prior admission, and are stable within hospitals over time."
Treating elderly individuals with near end-stage severe chronic disease and mental health illness, will absorb enormous resources with very limited benefits. Providing a significant portion of those resources to young Americans, and using less expensive culture-changing methodologies, may yield better long-term results. America needs to resolve its ambivalence over tobacco, alcohol, addicting substances, unhealthy food intake, exercise and work habits. It should facilitate education for all of our young people and devote adequate resources to building a healthy life foundation for our country.
Good luck, Mr. President-elect. My grandchildren's well-being will depend on the decisions you make.
As a lawyer and former President of the Harvard Law Review, you know very well that all that is in print is not true, that experts can honestly hold to strong but incorrect opinions, and that one should be skeptical of claims by anyone that he or she has "the" solution. Please use those skills in evaluating the hype about disease management.
The managed disease care solution falls apart under close scrutiny. The Fall, 2008 Health Care Financing Review, in an interesting series of papers growing out of disease management studies conducted by Medicare and Medicaid, shows that savings, if any are negligible. Brown and Peikes (15-Site RAndomized Trial of Coordinated Care in Medicare FFS") found that after two years, the treatment group experienced no gross or net expenditures savings when compared to the control. Esposito and Brown reported that a primarily telephonic patient monitoring and education service "show virtually no overall impacts on hospital or emergency room . . . .use" although for a subset of patients with congestive heart failure program reduced Medicare expenditures by 9.6 percent. In the paper "Evaluation of Medicare Health Support Chronic Disease Pilot Program," Cromwell and McCall's conclusions were consistent with the cited authors' interpretation of their data. Goldfield and McCullough's paper, "Identifying Potentially Preventable Readmissions" unsurprisingly showed that "readmission rates increase with increasing severity of illness and increaasing time between admission and readmission, vary by the type of prior admission, and are stable within hospitals over time."
Treating elderly individuals with near end-stage severe chronic disease and mental health illness, will absorb enormous resources with very limited benefits. Providing a significant portion of those resources to young Americans, and using less expensive culture-changing methodologies, may yield better long-term results. America needs to resolve its ambivalence over tobacco, alcohol, addicting substances, unhealthy food intake, exercise and work habits. It should facilitate education for all of our young people and devote adequate resources to building a healthy life foundation for our country.
Good luck, Mr. President-elect. My grandchildren's well-being will depend on the decisions you make.
Friday, November 7, 2008
A Brave New World - But Who Can Afford It?
The doctors' lunch table discussion on Thursday, Nov. 7, was a little different. Since the only oncologist in the group had left practice, we did not discuss the inability of oncologists to pay for an office stockpile of expensive chemotherapy drugs for their patients and the difficulties this caused for patients, oncologists, hospital and infusion centers to which these patients were referred for treatment. The difference yesterday that the complaint came from a new source, an experienced community nephrologist who described an insured kidney failure (not on dialysis) patient who need erythropoietin to produce blood. Because the doctor's practice was not generating sufficient income for him to stockpile a supply a erythropoietin, he gave the prescription to the patient whom he told to procure the drug and bring it in on the next visit. The patient came, but without the drug, saying that he couldn't afford the $500 prescription charge. This doctor went ahead and took care of the patient's need, giving him the medically appropriate dose of erythropoietin, but sent letters to the rest of his patients informing them that he will be unable to do this for them.
Recently, there have been studies and journal articles about the risks of giving too much erythropoietin. But less dramatic information about the difficulties patients are having in getting, paying for and benefiting from standard accepted medical therapies grab no headlines. As we move into a period of extraordinarily effective biologic products which relieve pain, suffering and premature death, our health system will have to grapple with the high costs of these products and their unavailability to many who need them.
Recently, there have been studies and journal articles about the risks of giving too much erythropoietin. But less dramatic information about the difficulties patients are having in getting, paying for and benefiting from standard accepted medical therapies grab no headlines. As we move into a period of extraordinarily effective biologic products which relieve pain, suffering and premature death, our health system will have to grapple with the high costs of these products and their unavailability to many who need them.
Thursday, November 6, 2008
What Is The Lesson of Obama?
The election of Obama teaches us, not only that a well-organized, dedicated and competent electorate will respond to an articulate smart and sensible leader, but that it will recognize its legitimate self-interest and take forceful action.
That lesson is applicable to our health care system. The Clintons tried to design a hierarchical system from the top down: it didn't work. Let our united voices help build a system, from the bottom up, which provides affordable appropriate necessary health care to all Americans. See my blog dated November 6, 2008,write your letters, and make your voices heard.
That lesson is applicable to our health care system. The Clintons tried to design a hierarchical system from the top down: it didn't work. Let our united voices help build a system, from the bottom up, which provides affordable appropriate necessary health care to all Americans. See my blog dated November 6, 2008,write your letters, and make your voices heard.
Wednesday, November 5, 2008
Voters: Set The Health Care Agenda
When Congressman Norman Mineta and I had a discussion about health care reform at his annual barbecue in the mid-90s, Norm, a very smart, seasoned and common-sensed San Jose Democrat, felt that neither Congress nor the Administration at the time was ready to act. As usual, he was right
Although health care has even greater public importance today, unless it's a high profile item on the national political agenda, nothing substantive will happen. Partisan politics, budgetary priorities and shortfalls, and our economic woes will block reform of our health systems. Major donors (i.e., insurers, hospitals, pharmaceutical manufacturers, chiropractors organizations, nursing homes, nursing associations and unions, physicians' lobbies, various unions and many others) will preserve their privileged positions. The public, patients and their families, will once again be ignored or stalled.
It's time for voters to use some of their chips - to write brief clear letters (especially the kind that go in the Post Office mail) to our Representatives, Senators, the Administration, and national political parties, making it very clear what we expect them to accomplish for health care. (If you can't write a letter, send an email, but note that email is not as effective at influencing political judgment.)
If you choose not to use your political chips, those major donors to the Republican and Democratic parties, candidates and functionaries, will be at the health policy table in a no limit to the stakes game. Setting an agenda in which health care needs are trivialized, they will divvy up the health care pot, and the public will once again be screwed. You can make a difference by writing a one page letter to your Congresspeople, the Republican and Democratic national parties, the Obama Administration, and your local newspaper:
!. First short paragraph: tell the recipients who you are, where you live, and that you are a voter in their districts (use your zip code); briefly describe the single most serious health system problem you have found.
2. Second short paragraph: describe a solution to the problem you have identified and describe the single most important thing that you want them to do.
3. Third paragraph: picture for them how your proposed solution will help.
4. Fourth paragraph: tell them why their advocacy for your solution to the problem you have identified will be in their best interests.
Politicians count numbers. If enough of us write to our politicians they will notice and respond. If we set their agenda, they will follow. After all, they work for us.
Although health care has even greater public importance today, unless it's a high profile item on the national political agenda, nothing substantive will happen. Partisan politics, budgetary priorities and shortfalls, and our economic woes will block reform of our health systems. Major donors (i.e., insurers, hospitals, pharmaceutical manufacturers, chiropractors organizations, nursing homes, nursing associations and unions, physicians' lobbies, various unions and many others) will preserve their privileged positions. The public, patients and their families, will once again be ignored or stalled.
It's time for voters to use some of their chips - to write brief clear letters (especially the kind that go in the Post Office mail) to our Representatives, Senators, the Administration, and national political parties, making it very clear what we expect them to accomplish for health care. (If you can't write a letter, send an email, but note that email is not as effective at influencing political judgment.)
If you choose not to use your political chips, those major donors to the Republican and Democratic parties, candidates and functionaries, will be at the health policy table in a no limit to the stakes game. Setting an agenda in which health care needs are trivialized, they will divvy up the health care pot, and the public will once again be screwed. You can make a difference by writing a one page letter to your Congresspeople, the Republican and Democratic national parties, the Obama Administration, and your local newspaper:
!. First short paragraph: tell the recipients who you are, where you live, and that you are a voter in their districts (use your zip code); briefly describe the single most serious health system problem you have found.
2. Second short paragraph: describe a solution to the problem you have identified and describe the single most important thing that you want them to do.
3. Third paragraph: picture for them how your proposed solution will help.
4. Fourth paragraph: tell them why their advocacy for your solution to the problem you have identified will be in their best interests.
Politicians count numbers. If enough of us write to our politicians they will notice and respond. If we set their agenda, they will follow. After all, they work for us.
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