August 27, 2008
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At the start of next year, the drug companies will no longer be giving pens and pads of paper to doctors. The rules regarding pharmaceutical sales practices have grown progressively more stringent over the past few years. The FDA already regulates what the reps say to physicians (they may only assert what is in the PI, or package insert). Now they will be very limited on other contact with physicians.
Thank goodness. Those pens and pads of paper were sending subliminal messages to me. I hear them talking to me in my sleep. I just have an insatiable need to prescribe unnecessary medications because of a ballpoint. It will be good to get out of this marketing hell these reps have put me in.
Citizens are worried about the influence these companies are having over us physicians, wondering if their efforts to influence are driving up the cost of care. One online petition site states:
Drug marketing is out of control. Help send a message to Congress.
Support the Physician Payments Sunshine Act, which will require drug companies to publicly report their gifts and payments to doctors.
Drug companies spend at least $25 billion each year marketing to doctors. We pay for that with every drug we buy. And studies prove that marketing causes doctors to prescribe higher-cost drugs. Some new drugs also have safety risks (like Vioxx). By increasing transparency, the Sunshine Act will help protect patients and help counter the skyrocketing costs of drugs.
Congress is also getting involved:
While it’s no secret that pharmaceutical companies lavish gifts on doctors — everything from free notepads and pens to meals to the more extravagant paid trips or seminars — most patients are in the dark about who, exactly, is courting their physicians. But Congress may be finally acknowledging this relationship, one important step toward creating a national gift registry so patients can track the perks Big Pharma is giving to their doctors.
In June, the nonprofit government watchdog Public Citizen testified before the Senate Special Committee on Aging in favor of federal legislation that would require drug companies to disclose payments to doctors. But the group urged lawmakers, before jumping on the proposal, to examine a Petri dish of existing disclosure laws. Although four states and the District of Columbia already have disclosure laws on the books, the group says they are “inadequate” and do not give patients a clear picture of how money is changing hands.
I do understand this concern. Advertising works, and there are definite financial reasons for the drug industry’s aggressive marketing to doctors. The pressure seems to be working, as witnessed by the pen and paper ban.
I guess it is appropriate congress is getting involved, since they are very familiar with the influence the drug companies can have over people and their behavior. From the Wall Street Journal:
Health Industry Pours Money Into Democratic Convention
The health-care industry has a lot at stake in Washington these days. Maybe that’s why the list of the Democratic convention’s host-committee sponsors is so full of big players from the health sector.
Among them: Merck, Amgen, Pfizer, AstraZeneca, Novartis, Mylan, Medtronic — (pause for breath) — Abbott, Walgreen, UnitedHealth, Eli Lilly and Anthem Blue Cross Blue Shield.
Nor are the companies letting the money do the talking. The CEOs of Pfizer, AstraZeneca, Eli Lilly, Amgen and Merck are all making appearances in Denver this week, reports FDA Legislative Watch.
And Pfizer was among the million-dollar donors that landed skyboxes at Invesco Field for Obama’s big speech Thursday, the Dallas Morning News reports.
As we noted earlier this year, the sector has shifted to favor Democrats over Republicans recently. But that doesn’t mean the Democrats are getting everything: There will be plenty of industry money sloshing around Minneapolis - St. Paul next week for the Republican convention.
Hmm…. I smell hypocrisy here. Isn’t this problem of at least equal importance to the short-skirted drug reps and gawking doctors? Is the lack of pens and paper in my office (which will boost the local economy as we go to Staples to buy it for ourselves) such a great accomplishment when Pharma (and every other industry) is buying influence with our government?
I don’t really care about the pens, but it seems a much bigger issue to me that corporate America has bought our legislators and are trying to influence our President. These are the people who are going to reform healthcare? These are the people who have a vision of how things need to be?
I’ve got an idea: let’s start a petition to prohibit them from giving pens and pads of paper to politicians.
Posted in American Medicine, Pediatrics, Rants
11 Comments »
March 9, 2007
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OK, now that I caught your attention, I need to explain (before some of the wacky folks who visit Flea start thinking I am in their camp). First off, aside from germ theory, sterile technique, and public sanitation, I think immunizations have saved more lives and improved the quality of more people’s lives than nearly any other scientific discovery. Second off, I do not think there is any merit to the whole thimerosal/MMR/autism "debate." I think vaccines are safe and should be used whenever possible.
So why say I hate immunizations? It is the business side of being a doctor that hates them, not the medical side. Immunizations:
- Are the largest line-item on our budget apart from staff salaries.
- Have incredibly small margins of profit, so any rejection, failure to pay by either patient or insurance company can turn our small profit into a loss.
- Are constantly changing, so it is never sure which immunizations are covered by whom, making it hard to know if we should bill the patient up-front or bill insurance.
Let me give a few illustrations.
Influenza Vaccine
It used to be that the influenza vaccine was something that we could not get our patients to take. "It just gives me the flu" was the common response when we tried to get patients get them. No matter what the evidence showed, patients just did not want to get that vaccine.
Then something strange happened. There were a few large flu epidemics and subsequent fear of a pandemic made people suddenly want to get the flu vaccine. Patients wanted flu shots, and our office ordered a large quantity of them for the flu season of 2005-2006.
Unfortunately, that was also the season when there was a manufacturing problem with the influenza vaccine and we suddenly could not get them. Now patients, instead of angrily refusing to get the vaccine, were furious that they could not get the vaccine. We actually had patients (who were not at high risk for influenza complications) scream at us because we would not give them a flu shot due to the fact that we were saving it for those who were at high risk.
This past year we again ordered a large quantity of vaccine, being assured that there was no manufacturing problem. We got our first 100 doses in September, but then were told it wouldn’t be until the end of November that we would get our next installation (of the 600 we ordered). Again we had angry patients.
To make matters more frustrating was the fact that Wal-Mart, Walgreens, and other pharmacies had plenty of flu vaccine. Why would we have problems getting them delivered to us while these businesses have plenty? I never got a good answer for that, but I have my suspicions that it regards a word that begins with "dol" and ends in "lar." In any case, we canceled the remainder of our shipment because we did not want to get stuck with 500 doses and no patients to give them to. We would lose serious money from doing this - besides, we could just tell patients to get them at Wal-Mart.
The other problem we face is the use of influenza vaccines in children. The current recommendations are that children from age 6 months to 5 years of age be vaccinated. Yet, as Flea summarizes in his blog:
Shinga over at Breath Spa for Kids tells us about an analysis and comment article in BMJ on the efficacy and effectiveness of influenza vaccines.
It turns out that the inactive vaccines we fleas give to kids under 6 aren’t all that effective. For patients 6-23 months old the vaccine is no better than placebo, according the Cochrane Database of Systematic Reviews.
Live vaccines perform better, but we can’t give them to kids under 6 years of age.
The author of the BMJ piece, Tom Jefferson (presumably no relation to the founding father, but one never knows) concludes with not a small amount of disappointment that inactivated vaccines have little or no effect on the outcomes studied in the literature. In many cases, Jefferson notes, the methods used in these studies are poor.
At the end of the day, according to Jefferson, we need better study designs. In the meantime, we ought to ask ourselves why we make policy based on such crappy evidence?
Okay, I’ll ask the question: Why do we make policy based on such crappy evidence?
So we have the live vaccine (the nasal spray) that works well but is not covered by many insurances (and runs around $50). You can only use that between ages 5 and 50 - those who are least vulnerable and hardest to access. Then you have the less effective killed vaccine (the flu shot) that is the only one you can give to the high-risk populations. The low-risk people don’t want to pay the high price of the nasal spray (especially if insurance does not pay), so they use up the supply of the high-risk population.
Sigh.
I am not looking forward to flu season next year.
Adolescent Vaccines
"Some insurances don’t pay for adolescent vaccines," my partner informed me yesterday. I wanted to give a girl the HPV Vaccine and the TDaP (The new vaccine for tetanus, diphtheria, and pertussis for teens and adults). We have to make these patients pay before getting the vaccine because we are not sure they will be covered by certain insurance companies. There have been several new vaccines for adolescents/pre-adolescents recently, including:
- Gardasil - the HPV vaccine. This is recommended by the AAP and CDC to be given to all girls starting at age 11. While there is a big controversy surrounding the vaccine, that is not what I want to address. The real problem for us is that it costs around $120 per dose, requires three doses, and is not covered by all insurances.
- Menactra - this is the meningiococcal vaccine. Meningiococcus is a bacteria that causes a devastating form of meningitis in teens and young adults (occasionally in younger children). It is on every doctor’s "dread" list, as it very rapidly kills previously healthy young people. This new vaccine is quite effective to prevent this disease and is recommended at age 11. It is required for entrance to college, yet many insurance carriers do not pay for it.
- TDAP - This vaccine is the tetanus booster that also treats pertussis, the bacteria that causes whooping cough. Studies have shown that the rate of pertussis in adults has steadily increased over the past number of years and this new vaccine helps prevent that. Yet insurance still does not reliably cover this.
On cue, I got the following communication from the AMA as I was writing this:
The AMA and the American Academy of Pediatrics co-hosted a meeting of key stakeholder organizations last week to address many challenges for patients who need vaccinations and the doctors who provide care for them. One of the outcomes of the Immunization Congress is to establish several task forces to pursue solutions to a specific set of problems surrounding access to vaccination, medical practice costs, public health system shortfalls and how vaccines are financed. Participants included 140 government and public health officials, manufacturers, distributors, private payers, advocacy organizations, pharmacy groups, community immunization providers and medical societies. In related news, physicians who are experiencing problems with inappropriate insurance reimbursements for immunization administration and vaccinations are encouraged to file a compliance dispute under the multi-district litigation (MDL) settlements with six of the nation's largest health insurers. This process has proved effective in making vaccines more available to patients, particularly in North Carolina, where several outbreaks of meningococcal illness on college campuses created demand for a vaccine that had been prohibitively expensive for students.
Finally, the insurance reimbursement for these vaccines is often at or below the cost it is for us to buy the vaccine. We can (and do) make it up with "administration costs," but end up having to raise the price for an already expensive vaccine just to make a profit.
So to summarize:
- Immunizations are wonderful things that save lives and should be used more, not less.
- Doctors have to buy the vaccines at very expensive rates and may not be paid by the insurance company, forcing them to charge the patient up-front or risk losing any profit.
- The large number of new vaccines has made this situation far more confusing for patients and physicians.
- Insurance companies capriciously set rates that are often not reasonable. They often continue not to pay for vaccines that are either required (for college entrance, for example) or greatly advantageous for patients.
- Flu season has become a yearly debacle for my and many other physicians’ offices.
Rant completed.
Posted in American Medicine, Pediatrics, Rants
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August 26, 2008
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If you want grand rounds as you like it, then head on over to Rural Doctoring. Measure for Measure it is definitely well done; not a comedy of errors. Believe me, this is not much ado about nothing, it is truly an epic tale. It may seem like a lot to read, but when you finish you will agree that all’s well that ends well.
This grand rounds, by the way, is co-authored by none other than Zippy the Lobster, who is raising money for brain cancer research. If you have not given to Zippy’s cause yet, please click on the Firstgiving icon on my sidebar.
Posted in Grand Rounds
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August 23, 2008
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It happened today.
It’s a sinking feeling in the stomach.
The patient comes into the office with a chief complaint and set of symptoms that worrisome, or the x-ray comes back with a “suspicious area” on it. It sounds like cancer. My mind explores the possibilities, hoping for a diagnosis that is not so bad, but the elephant just won’t leave the living room.
Having practiced for many years, I have had to give bad news many times. It does get easier, but it never is easy. I am standing at a major turning-point in a person’s life. The words that come out of my mouth will hit them like a sledgehammer, shattering what is “normal” and leaving an uncertain future.
There are a few things that I have found are most helpful in this setting:
Don’t beat around the bush - most of the time they already suspect something is wrong. It does no good to use euphemisms. If it may be cancer, then say “it may be cancer.” It is extremely important that your wording is specific, not vague. - Give a specific plan - It is extremely important to give patients something to focus on in the immediate future. Answer the “what now?” question. I usually call the specialist in person and get an appointment right away. I don’t leave the scheduling to my nurse or referral coordinator. It is extremely important for people to walk out of the office with a plan. Their lives are suddenly full of uncertainty, so it’s not right to add to it.
- Don’t conjecture - I try to stick with what I know for sure. I try not to answer questions like “how long will I live?” or “will I need chemotherapy?”. My job is to get them to the next step. A “mass” is not the same as “adenocarcinoma.” If these questions are asked, I tell them that the specialist will make the diagnosis and then the longer-term plan will be more clear.
- Don’t make them wait - If more tests are needed, don’t schedule them for two weeks - even if it would not matter clinically. It is simply cruel to tell someone they might have cancer and then make them wait to know what it means. If necessary, I schedule the scan myself or talk to the radiologist to get it scheduled. If an oncologist or surgeon schedules an appointment for two weeks (or even 3 days), I call them personally and ask to get the patient in sooner. Today, if possible.
- Bring them in - It is awful to call someone and say, “your doctor wants you to come in and go over your test results,” but it is worse to give those results over the phone. As uncomfortable as it is in person, it is important that you are with them. It shows that I understand how earth-shattering this news is. To do it over the phone makes it seem like you don’t care.
- Don’t try to find “silver linings” - I have had many cancer survivors tell me that their cancer really helped them see what was really important in life. But that means nothing to someone who just got bad news. Once you say the word “cancer,” any thing you say to try to make things better will fall on deaf ears. What people need is your sympathy and a clear plan - that will comfort far more than any platitude.
- Give comfort - Sympathy literally means to feel pain alongside someone. You feel pain. The pain you feel giving bad news is shared with their pain receiving that news. I also will give these people special access to me if they need anything - my cell phone or a back line number. They need to know where to get answers. Also inquire about support systems - do they have family in town, or a church they belong to?
- Follow up - I don’t just pass people over to the specialist. I want them to still be my patient. I either ask them to call when they know what is going on, or I call them myself after a reasonable length of time. If necessary, I even schedule them to come in simply so I can hear what is going on. This makes people feel less isolated and gives a chance to ask questions.
One of the great honors of being a doctor is to be there at the critical times of a person’s life. Not all of those times are not happy. I think people need you most as a comfort and help at these times. It is very hard for a doctor to cause pain by their words. But the way in which bad news is given can either add to the pain or start the healing process.
Posted in Being a Doctor
18 Comments »
August 22, 2008
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Many have commented on my laments at the difficulty of practicing primary care in the US. One of the recurrent themes centers around whether or not physicians should just stop accepting insurance altogether.
One reader commented:
For me, the doctors I see most frequently simply don’t take insurance. Less office staff, more doctor time. I pay a 30% out of network copay, which often doesn’t work out to much different than what my office visit charge would have been anyway. those doctors take phone calls during the day, call back at night, etc. The minor difference in cost is worth it!! they are always booked and seem to be doing fine financially. In this area, in certain specialities, if a doctor is any good, they have opted out of insurance.
If you can’t get an incentive system with the insurance companies, I would consider the no insurance model to be a good one.
And another:
We sit and wait for someone else to fix the system do not become proactive, and wait each year for the bad news from the insurer, medicare, etc.
Patients….fire your classic insurance company, opt for a very high deductible or a major medical polilcy.
Doctors….stop taking insurance except for surgeries, hospitalizations and/or major workups.
You will see how fast the insurers belly up and change their tune…..Americans unite, we do not need them…
In his editorial in USA today, Kevin Pho points out that over 40% of Texas physicians don’t accept new Medicare patients. Truly, if the recent Medicare cuts had not been stopped, our practice would have lost money on many things we do and would be forced to strongly consider doing the same.
The business argument for quitting insurance is solid. I would not need billing staff, could give upfront fees to patients, and could set my rates as I saw fit. I would not have to do authorizations for procedures - passing any hassles off to other physicians. In my market, I could even charge an annual fee for the many IT services we offer above and beyond what most practices offer.
Ironically, I could also start not charging patients if I choose. Since I am a Medicare provider, to no-charge a non-Medicare patient would be considered fraudulent. Why? Because I am not also extending that discount to my Medicare patients.
So why don’t I do it? Why do I hang on to the arcane, complicated mess of medical insurance?
If you ask a patient who their doctor is, they will almost always refer to their primary care physician. I am their doctor and they are my patients. As a physician, I have taken on the task of helping my patients navigate through their sicknesses as well as working to prevent them. This is the reason I chose primary care: I wanted to build long-term relationships with my patients. I wanted them to see me as their doctor.
Specialists deal either with a single body system (such as heart or lungs) or perform procedures the patient needs on the short-term. They do build long-term relationships with some patients, but it is only the sicker, more complicated patients. Even then, they (hopefully) send their notes back to the patient’s PCP, so someone can know and understand the over-arching needs of the patient.
Dropping insurance would come at a cost: I would lose a large number of my patients. I like a lot of them. I have helped them through tough times and have enjoyed having many of them. They aren’t all demanding. They aren’t all frustrating. They are just caught in the same mess I am in. It is very hard to cut them loose in a time when the PCP market is shrinking.
This is a big reason as to why the trust between patients and doctors is going down. Physicians are being forced to decide between money and patients. They are being forced to look after themselves when their job is to look after others. This contradiction is not lost on the patients and causes doctors to become suspect in their eyes. The focus on the business of medicine has taken the focus off of the practice of medicine. This is why many patient feel “like a number.”
It amazes me that I would even consider dropping insurance. The cost would be huge. I would lose many long-term relationships. They would feel jilted and betrayed. It would appear that I am “all about the money.”
Even though my income would go up if I did, I am not ready to do that to my patients. It is emotional, not economic.
Let’s just hope that things change before I am forced to stop being their doctor.
Posted in American Medicine, Being a Doctor
10 Comments »
Hmm…. I smell hypocrisy here. Isn’t this problem of at least equal importance to the short-skirted drug reps and gawking doctors? Is the lack of pens and paper in my office (which will boost the local economy as we go to Staples to buy it for ourselves) such a great accomplishment when Pharma (and every other industry) is buying influence with our government?
Avoid being nominated for Vice-president.
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