Wednesday, February 25, 2009

Obama on Health Care

For starters, let me say I am a huge fan of our new President. I voted for him, donated to his campaign, and am a proud member of Doctors for Obama

I listened closely to his speech last night looking for signs of what is to come next in health care reform. Though his speech was historic, to my surprise it left me somewhat disappointed on the matter of health care. Below is what the President said:

Our recovery plan will invest in electronic health records and new technology
that will reduce errors, bring down costs, ensure privacy, and save lives. It
will launch a new effort to conquer a disease that has touched the life of
nearly every American by seeking a cure for cancer in our time. And it makes the
largest investment ever in preventive care, because that is one of the best ways
to keep our people healthy and our costs under control. This budget builds on
these reforms. It includes an historic commitment to comprehensive health care
reform - a down-payment on the principle that we must have quality, affordable
health care for every American. It's a commitment that's paid for in part by
efficiencies in our system that are long overdue. And it's a step we must take
if we hope to bring down our deficit in the years to come.

In summary: Electronic Medical Records, the cure for cancer, preventative care, and universal coverage. Though all of these things are important, I am not sure this is the right focus.

I am in favor of Electronic Medical Records, but we have to be careful how we invest in this. I have already commented that the almost $20 Billion dollars from the stimulus package may not be well spent. It goes primarily to hospitals, which probably already have their own systems. The key is interoperability, and I don't know if there are any provisions for this in the bill. Also, the VA system has an amazing electronic medical record. Why not adopt this system and use the money to give every health care provider (hospital, office, clinic) the ability to access this one shared system rather than just padding hospital's bottom lines?

I would love to see the cure for cancer, and we have made great strides. I support more research in this area. However, cancer is not one disease but many complex diseases. Though cancer research is certainly a worthwhile cause, money spent on it today and in the near future will do nothing to improve the health care crisis we face today. I am for spending money on cancer research, but if funds are limited, we need to first spend money on fixing the current system now.

As a primary care physician, prevention is what I do every day. Prevention is key and critical. One of the reasons we spend so much on health care is because as a nation we are not well. Prevention is a broad term, and it is not clear from the President's speech what his focus is on. However, part of prevention (and an important part in my biased opinion) is strong relationships with, quality care by and reasonable access to primary care physicians. I am extremely disappointed that there was no mention of improving our primary care infrastructure. I wish he would have said something like "we will invest in primary care, because this is key to comprehensive health care reform"

Similarly, universal coverage is great, but somewhat has to be there to see all these patients with health insurance. This is the lesson we can learn from the Massachusetts plan. No policy maker or pundit, including our President, should mention universal coverage without mentioning improving access to primary care providers. Fewer students are going into primary care, more and more primary docs have stopped accepting insurance or have gone concierge.

I continue to support our President, and believe he will lead us down the right path. He has a cadre of experts in health care policy that are phenomenal. In addition, his speech essentially mandated that health care reform will not wait, which I am thankful for. Perhaps I am reading too much into a political speech. However, the center of any health care reform must address improvement in primary care.

Tuesday, February 17, 2009

Common Things

Regular Check Ups for Men
Health News journalist Gary Schwitzer beat me to the punch in his critique about the Washington Post's article on health care screening for men in his post Disease-mongering by the Washington Post: here we go again.
Mr. Schwitzer correctly points out that many of these recommendations are not uniformly agreed upon or evidenced based, and yet they are treated "as if they were handed to Moses on stone tablets ."
Being from Minnesota, I am guessing Gary reads the online version, and would probably be even more miffed to know that the print version (which I get being in DC) has pictures of celebrities for the various age ranges (Justin Timberlake for 20's, Will Smith for 40's, Harrison Ford for 60's) as if these celebrities get these studies done or endorse the information.
My favorite piece of misinformation is the testicular exam which the Post claims is recommended for men 20-35, including regular self-testicular exams. Except the U.S. Preventive Services Task Force (USPSTF) actually recommends against this, giving it a Grade D recommendation. This means not that it is controversial or their is evidence lacking like prostate cancer screening, but that there is actually evidence that it may even be harmful. Testicular cancer is one of the most curable cancers we have. Lance Armstrong had metastasis to the brain, and look how well he did. Guys who are checking their testicles regularly are likely to find something that is not harmful/normal and will only cause them needless worry, and in some cases, a few unnecessary tests.

I highly recommend the USPSTF's pocket guide to screening. Though there are some things that are controversial that they don't recommend that I will often do (like prostate cancer screening), this is a very good starting point for what men and women should be doing.

Common Colds
My university's newspaper interviewed me for an article about myths regarding the common cold. The questions the young reporter asked were quite good and common questions asked by patients. Here's the link to the full article, a quick summary:
  • The flu shot does not give you the flu, but can cause mild symptoms
  • Vitamin C does not help prevent or treat the common cold
  • A wet head in cold weather will not cause a cold, but can increase your susceptibility to catching a virus that will cause a cold
  • Chicken soup actually works (with evidence to prove it)
A few things she left out:
  • Colds are caused by viruses. Please don't ask your doctor for antibiotics just because you feel "really sick." They will not help, and an only increase strains of resistant bacteria.
  • The flu shot is only protective of influenza which is one of many, many bugs that can make you sick. Just because you got the flu shot and then caught a cold does not mean it didn't work.
  • All pill forms of decongestants are now over the counter. This is part due to money issues and part due to FDA regulatory changes. The bottom line is that for a cold, there is little I can offer you in the way of a prescription that you can't get over the counter.
  • Fever is not necessarily bad. It is the body's natural response to fighting a cold. You are literally burning up the virus. Don't treat a number. If your temperature is 101, but you're not miserable, not taking a Tylenol might be a good idea. However, if you simply feel rotten, taking this will probably not hurt and can certainly make you feel better.
  • Most cold medicines come in combination. It is often disorienting to try to figure out what the active ingredients are in each variety of Robitussin. Most colds cause congestion, so you want something with a decongestant in it. In general, antihistamines just make you sleepy and can thicken secretions, thus making congestion worse. Antihistamins should be mainly reserved for allergies. Guaifenesin, the active ingredient in plain Robitussin, may or may not help, but probably doesn't hurt. Dextromethorphan (the DM part of Robitussin DM) does reduce a cough. Thus for a simple cold, I would take a plan decongestant +/- Guaifenesin, and add DM if a cough is present. I would avoid combinations that contain antihistamines. I would also take my pain medicines/anti-pyretics like acetaminophen and ibuprofen separately and not in combination.

Wednesday, February 11, 2009

$19 Billion For Health IT-Money Well Spent?

Medpage today reported that in yesterday's Senate approval of the stimulus package, that $19 Billion dollars would be allocated to health IT. According to the MedPage report, "The Senate bill allocated about $19 billion to upgrade hospitals' electronic records systems and limited how much an individual hospital could receive to $1.5 million."

Granted, this is only about 2% of the entire stimulus bill, but $19 billion is a lot of money. I am all for improving health IT, but is this where we want to spend the money? I am just a doctor, not a politician, political pundit or economist; so maybe I don't understand the stimulus plan. I thought that the point of the stimulus plan was to create jobs and help people. Since there are several proprietary products on the market, it is unlikely that spending on health IT will create a lot of extra jobs, but rather sell a lot of softwared and some hardware. More importantly, who is the health IT spending helping?

There are 7,569 hospitals in the US. That comes to roughly $250,000 per hospital, though not every hospital gets the same amount (and there is a limit of $1.5 million for an individual hospital). That's a lot of money. Do we really want to give a quarter of a million dollars to each hospital to improve their health IT? Many hospitals already have their own electronic medical records? Do they really even need this? What about the 20% of the hospitals that are for profit, are they getting some of this money?

There is no question that Health IT will substantially improve the quality of care delivery in this country, and in the long term is a worthwhile investment. The real question is how and where should we invest? I would argue that the hospitals are not the best place to go. Fortunately, most Americans with health problems are not in the hospital. Certainly hospitalized patients comsume more health care dollars, but there is no good evidence that health IT actually saves money. Would it not be better to invest in Health IT that actually keeps patients out of the hospital? In addition, as mentioned, many hospitals already have an electronic medical record/electronic ordering, whereas most practicing physicians (especially primary care) do not have an EMR. Would it not be better to give $85,000 to each primary care physician to set up his or her own EMR? Better yet, use the money to come up with a system that actually works, is easy to use and distribute, improves quality of care for all and decreases costs?

Health IT is important, and should be an important part of health care reform. However, giving $19 Billion directly to hospitals to beef up systems that many already have is not money well spent.

Monday, February 9, 2009

Fibromyalgia and the Problem with Dissing Pharma

The Washington Post today published an AP report called Drugmakers' push boosts 'murky' ailment. Though the AP's Matthew Perrone's piece is not without some balance, you get a sense of where the article leans through the title. When it comes to heath care, the media loves a few things: medicines that are scary and can harm you, the next miracle cure or diet, and of course big bad pharma.

The article reports on how drugmakers Eli Lilly and Pfizer donated more than $6 million to nonprofit groups for medical conferences and educational campaigns of fibromyalgia, a disease that that affect 6 to 12 million people in the U.S., mostly women, and it not well understood. Because of this, there are some that are even skeptical that fibromyalgia is a real medical condition.

The focus of the article is that the drugmaker's donation is not out of good will or charity, but to boost the sales of their drugs for this "murky" condition. They state that $6 million is nothing compared to the $125 million or so that each company spent on direct to consumer advertising or the $300 million dollars in sales that the companies made.

All these numbers may be true, and there is no question that pharma is not a charitable foundation. They are for-profit companies and seek to make a profit. The problem is that despite limitations in our understanding of this disease, fibromyalgia is a real illness. Just because we don't know what causes it, doesn't mean it is not a disease. In addition, the drug company's medications actually work. Both drugs have been approved by the FDA because they show some improvement in pain compared to placebo in randomized clinical trials. For certain patients suffering with this disease, these medicines have changed their lives for the better.

According to the American College of Rheumatology, fibromyalgia is a real condition. The millions of people who suffer with fibromyalgia consume health care resources to a similar extent to patients with other chronic diseases such as diabetes mellitus and hypertension. I know the misery that some of my patients suffer with, and a quick Google search turns up a ton of bloogers such as fibromyalgia diary blog, The Fibromyalgia Research Blog , an blogger and a community on revolution health. I doubt these folks have been provided hidden funding from evil pharma to promote a disease in order to raise profits.

Though this condition is still not understood, there is little research in this area compared to other chronic diseases. According to the The American Fibromyalgia Syndrome Association (AFSA) in 2008, the National Institutes of Health (NIH) expected to award $393 million to study hypertension compared with the $9 million it planned to award for researching fibromyalgia. Why aren't more research dollars being spent on fibromyalgia? If pharma not only provides treatments for this condition, but also funds research and advocacy groups, should we really crucify them for this?

Health care costs are through the roof, and in order to decrease the costs of prescription drugs we will need to work with the drug companies. However, like it or not, pharma supports most of the research for therapeutics and funds a huge amount of education. Though it would be nice if funding for research, advocacy and education came from less biased sources, do you really think the government or tax payers are willing to fund this, especially now during one of the worst economic crises in history? You can't have your cake and eat it too. The media should certainly criticize pharma (or any corporation) when they do something wrong, but lay off them when the do something right.

Sunday, February 8, 2009

How to Save on Prescription Medications

In these tough economic times, people both rich and poor are looking for ways to save a few bucks. The New York Times just published an excellent piece on Strategies for Saving on Prescription Drugs. Though many patients have health insurance that covers prescription drugs, even co-pays on preferred drugs can add up. I actually blogged about some of these things back in June before the economic crash in my post Save Thousands On Your Health Care.

The Times offers several suggestions, including:
Use generics when you can. In many cases, a generic will do just as well as a more expensive brand name medication. You should ask your doctor whether a generic could be used instead of a branded prescription. Generics are just as good as the "real thing" and patient's fears about getting an inferior product are unfounded. Please see my post Generics Just As Good As Brand Name for more details.

Use a preferred branded drug. Generics don't work all the time. However, there are usually several options for branded prescriptions and your insurance likely has one it prefers, based on the deal your insurance company made with the drug manufacturer. Non-preferred brands will cost you more than a preferred brand, so if you need a branded drug, make sure it is a preferred one.

Split Pills. Pill splitters are relatively accurate and only cost a few bucks. For example, if your bad cholesterol level needs to be lowered by 50%, even the highest dose of simvastatin won't cut it. If Crestor is a preferred drug, rather than taking 20mg of Crestor, have your physician write for 40mg of Crestor and split this in half. This will save you and your insurance company money.

Use mail order. Most insurance companies use mail order prescriptions. Buying in bulk saves them lots of money, and they will pass some of these savings to you in the form of lower co-pays. If you are on medications you take every day, use a mail order to send you 90 day supplies. This will not only cost less, but also save you on trips to the pharmacy.

Here are a few others that I have come up with:

Really know your formulary. As mentioned above, there are a variety of branded drugs of which one will usually save you money. However, the process is so complicated that unless your physician uses an electronic medical record that communicates this information to the doctor and updates it frequently, there is virtually no way your doctor will know which drug is preferred, and will usually take his/her best guess. More importantly, pharmacies will know which drug is preferred, but have no obligation to tell you this. In addition, they get kick backs from the drug manufacturers as well, so are often incentivized to give you the more expensive prescriptions. I have written before about the albuterol HFA confusion. Some pharmacies are actually illegally switching patients prescriptions to a more expensive product, which costs the patients more while the pharmacies make more profit. The way to protect yourself and save money is to go to your insurance company's web site and look of their formularly. See if the prescription you have is the preferred one BEFORE getting it filled by a pharmacy technician. If it is not, ask your doctor for an alternative.

Look for coupons. In addition to political pressure, more and more drug companies are doing away with samples because it simply costs them a lot of money. Making pills are expensive, and the drug companies know that most samples never get used. Especially in light of pharma's economic problems, coupons are rapidly taking place of samples. They accompany a prescription and are usually in the form of a free 30 day supply, or money off the co-pay. This is one way that branded products that are not preferred go around the insurance companies, but issuing coupons. You need to look at the economics yourself, because it depends on the coupon value and the cost you pay for branded vs. unbranded prescriptions. For example, let's say you need a branded cholesterol medication. Lipitor is preferred on your insurance at a monthly cost to you of $20 and Crestor is the non-preferred brand at a cost to you of $35. You would obviously go with the Lipitor. However, if you can get an up to $25 coupon off your co-pay, the non-preferred drug actually becomes cheaper. Many coupons are renewable (last for 6-12 months), but some are not so be careful.
If your physician does not have these coupons in their office, most drug company web site have them. Before you fill a branded prescription, check for coupons.

Ask if pills can be combined. Many physicians don't like combination pills, single pills that have two medications in one pill, because they feel if there are side effects they won't know which one to change or if the medication is not working, they won't know how to increase the dose. Though this is not entirely untrue, it probably isn't that important. In addition, once you are on a stable dose of two pills, if they can be combined, they should. It is easier to take one pill instead of two, and this will be one fewer co-pay for you. There are many pills that now come in combination, including some generics. One example is Caduet which combines Norvasc and Lipitor. Norvasc is now generic, Lipitor is generally at a preferred tier, and the preferred statues of Caudet varies from insurer to insurer. You need to look at what you pay for each tier, because sometimes the price of a generic plus the price of a preferred drug is still more than the price of a non-preferred drug.

Start on samples. There is no question that drug companies make samples so that doctors will use their medications, and this will ultimately increase the overall cost of prescriptions. Also, the notion that samples go to the poor has been debunked, and I have commented on this in the past. That said, I have had more and more requests for samples from my patients with good insurance during this economic crunch, as co-pays add up and really cost. In my opinion, the reasons samples are beneficial is because they allow doctors and patients to try out a new drug before committing. If you are starting on a new drug, go to the pharmacy and pick up a prescription of a 30 day supply, and then have sided effects after the first few doses, you have wasted almost a month of medication. Your doctor can write for something else, but your insurance company will not re-fund the money you paid.

Wednesday, February 4, 2009

Patients, Physicians and Bloggers Unite for Diabetes

Patients, doctors, and in particular bloggers have joined together to try and improve diabetes research and treatments. MD Consult News (may require subscription) is reporting that "Prominent diabetes specialists, advocates, and educators are preparing to challenge the Food and Drug Administration’s guidance on safety testing for diabetes drugs, arguing that the new standards are excessive and threaten to stifle drug discovery at the expense of patients who need more treatment options."

I have previously blogged about this issue in my previous post. Rough Times for New Diabetes Drugs: The Diabetes Conspiracy Part III. It is particularly concerning to me that the FDA's decision to make it virtually impossible for any new diabetes treatment to get approved is primarily based on one controversial and highly publicized study whose lead author may very likely be the next head of the FDA. Could this study have been politically motivated?

The bottom line is that despite many of the treatments we have available, the majority of diabetics in the US are not well controlled, leading to substantial morbidity and mortality. We need new therapies. Though safety if critically important, the FDA recommendations are not only restrictive and excessive but also not really scientifically based, since the results of the one controversial study that generated this recommendation have all but been disproved (see here and here).

I am glad to see I am not alone in wanting this issue resolved. The following excellent bloggers have already signed up:

Amy at DiabetesMine, Marsten at SugarStats, Nadia at Diabetes Health, Kerri at SixUntilMe, Allison at Lemonade Life, Gina at Diabetes Talkfest Blog, Fran at Diabetes Day by Day, Kitty at Diabetes Living Today, David at Diabetes Daily, Bernard at the Diabetes Technology Blog, David at Mendosa, Howard at dLife, and Scott at Scott's Web Log

To look at and sign the petition, please CLICK HERE
The goal is to get 20,000 signatures.