by Brian L. Grant, MD
As noted in this New York Times article, more health plans are refusing to cover certain drugs unless the companies charge less for them.
Imagine a world in which food, housing, clothing, cars or other items we consume increased in price by 14% or more per year? What keeps this from happening in general is the pressure of the free market, responding to the pain that we feel every time we pull out our wallet to pay for something – motivating us to shop smartly, consider alternatives, and sometimes make a choice that is not what we would select if money were no object. How many of us work in companies where we can raise our prices by double digits annually, or see our pay increase by similar amounts year over year?
Not so in the world of specialty pharmaceuticals. We have been shielded from price by the impact of insurance payments and convinced that nothing but “the best” is good enough for us patients and that the insurance company writing the check (after our employers or government pay for the insurance), has no business exercising its economic power and “interfere” in what doctor thinks is best.
Nonsense! So long as we have abrogated payment to a third party, these third parties, be they government or commercial, have an obligation to introduce competition and create some pain and perhaps friction in the system. The days of patients paying for their own care are not likely to return. Kudos to the creative efforts to weigh cost and benefits, create formularies, and hopefully drive down some of the egregious pricing that appears to be in play.
Some drug companies choose to do end runs around co-pay requirements by giving rebates to patients, while still getting the big dollars from the carriers for the higher priced drugs. The move to escalate the fight by deleting certain drugs from formularies, forcing patients to pay the entire cost if they or their doctor refuse the alternatives, is a rational and needed escalation.
In the fall, 30,000 Puget Sound-area Boeing employees and retirees will be able to choose between two accountable care organizations (ACOs) for their personal and family health plan, a coverage option Boeing is calling the “Preferred Partnership.”
There were more than 600 ACOs nationwide at the start of the year, and they are being touted as a key strategy for curbing U.S. health-care costs.
The fundamental idea is that doctors and hospitals are rewarded for keeping and making patients healthy, rather than a “fee for service” approach where they earn more for prescribing lots of tests or scheduling appointments regardless of how a patient fares.
The contracts also include quality goals that matter to patients, such as the ability to schedule appointments in a timely manner and maintaining patient safety and satisfaction.
There are additional benchmarks tied to costs, including reducing readmissions to hospitals after treatments and effectively managing chronic conditions such as diabetes and heart disease.
Dr. Elliott Fisher, director of the Dartmouth Institute for Health Policy and Clinical Practice in New Hampshire, is hopeful the ACOs can help heal an inefficient health-care system. “There is so much waste,” Fisher said. “ACO arrangements are intermediate steps toward more fundamental reforms.”
Brian L. Grant MD
This editorial from the Seattle Times by Roger Stark raises a number of issues worth discussing. The recent controversy about the VA has been long in the making. It is about culture and corruption. But it also allows us an opportunity to look more closely at the fundamentals of the VA, ask tough questions and perhaps make some basic changes.
There is a lack of understanding about the VA and people tend to mix up and confuse issues. And the reverential manner with which it is spoken by most elected officials makes it difficult to have meaningful conversations.
My time in the VA is quite dated, going back to several rotations as a resident physician in the 70′s and 80′s. Back then I was struck by a number of observations:
- Most admissions and patients were there for conditions that had nothing to do with military service. And a number of them were receiving permanent pensions because their conditions were identified in the course of service. Chronic Schizophrenia comes to mind. We now know that this is a biologic condition, not environmental, coincidentally becoming symptomatic in late adolescence and early adulthood when individuals may be in military service. If one lasted long enough in service, an early discharge and a lifetime of benefits would result, though the disease would have developed irrespective of service. Other medical admissions were often older Veterans with the usual maladies of age and lifestyle that one encounters in any hospital, such as heart and lung diseases, often flowing from lifestyle issues like tobacco use and diet.
- These hospitals were large institutions, often in the same vicinity as other facilities and clinics that offer excellent care options.
- The staff were of high quality and some, like the Seattle VA, were teaching institutions affiliated with an excellent medical school, and helped train medical students and residents. They cared about their patients.
Setting aside the current controversy, we should ask several questions about the VA and where it should fit in the US Healthcare system:
- What is the social contract between the VA and Veterans? Who should it serve and why? What is the distinction between those injured in the course of duty and those not? Should those who have served but have no injuries from their service be entitled to free health care via the VA system?
- Does the current VA disability system work and when should an injury translate into economic benefits vs. treatment for the condition?
- What are the moral hazard and political implications of tying an injury to compensation? How does compensation muddy diagnoses like PTSD and traumatic brain injury?
- Assuming care is owed or committed, is a free-standing government run system the best way to accomplish this? What are the alternatives?
Readers of this blog know that the current healthcare system is not defended in terms of its economics. It is expensive and costs inflate far in excess of other countries with quality systems or the overall US economy. And there are inherent problems in a system where doing and procedures are rewarded while prevention and thinking is not. Furthermore the system is one where the patient is generally ignorant and disengaged on costs and treatment options and believes or acts as if the details and cost of care is an entitlement owed to them by their employer or government. This trend may be changing as cost sharing via copays and deductibles is growing under many policies. Most of us spend more time shopping for a TV set than a medical procedure or hospitalization that will cost 20-50 times as much or more, because with the TV and other personal expenditures, our interests lie in getting the best value for price.
Once we decide which Veterans to serve, could this not be better accomplished without a massive VA treatment bureaucracy? We have perfectly workable if imperfect government payment schemes including Medicare that can easily be ported to the VA and allow eligible Veterans to receive care from the facilities of their choice in the community.
Centers of excellence providing care for conditions unique to combat could be formed in partnership with high quality medical schools and research institutions for conditions such as amputations and combat-related PTSD.
Current VA resources and staff could be re-deployed into the private sector, where shortages exist presently and where demand would increase with Veterans entering the same system.
Is the current system inherently flawed and rather than focusing on current corruption, are bigger questions needing to be asked and answered?
Have you ever read their on-line ratings before you’ve gone to see a new physician? It seems like a logical thing to do — after all, you’re trusting a stranger to make decisions about your health that are quiet likely to be life-affecting. That is, after all, why you are going to see them in the first place.
Yet just how useful or accurate are on-line ratings? This Atlantic Monthly article explores the question, pointing out some obvious dilemmas: reviewers are often influenced by secondary considerations such as easy access to parking or their waiting room experience, and there’s no guarantee that the reviewer was even seen by the physician being reviewed.
To top it all off, there is evidence that satisfied patients are not the best cared for or healthiest. A March 2012 study in the Archives of Internal Medicine showed that patients with the highest satisfaction scores were more likely to be taking prescription medications, visit doctors’ offices, and enter the hospital. They were also likelier to be in poor health and die in the ensuing years. Read more…
Almost a third of the world population is now overweight or obese - about 2 billion people worldwide. No country has been able to curb obesity rates in the last three decades, according to a new global analysis released in May, led by Christopher Murray of the Institute for Health Metrics and Evaluation at the University of Washington. He and colleagues reviewed more than 1,700 studies covering 188 countries from 1980 to 2013.
“Our children are getting fatter,” Dr. Margaret Chan, the World Health Organization’s director-general, said bluntly during a speech at the agency’s annual meeting in Geneva. “Parts of the world are quite literally eating themselves to death.”
Would you travel around the world for a tattoo? More than 5,000 women have, to visit Little Vinnie’s in Finksburg, Maryland, where proprietor Vinnie Myers specializes in 3-dimensional nipple tattoos, an important final step in breast reconstruction after cancer surgery.
After a woman undergoes a mastectomy and breast reconstruction, the darker, sensitive skin of the nipple and areola is usually removed entirely. Surgical reconstruction is possible, but obtaining a tattoo allows women to forego further surgery and the resultant scar. Mr. Myers has been providing such tattoos since 2001, introducing a new specialization that has helped thousands of women worldwide. Read more…and watch the video.
by Brian L. Grant MD
As a forensic psychiatrist, I find myself as pained as the rest of society when a mass murder takes place. But like Dr. Friedman notes in this article, I am also aware that efforts to accurately identify and intervene with, in advance of a tragedy, those individuals who are going to commit such acts is impossible. For every person who commits such acts, there are many more with similar personality and mental health issues who would find such acts unthinkable, just as there are those who kill and maim with no obvious mental health impairments. One can’t confine those with a psychiatric diagnosis without casting a net that would include millions of productive individuals who pose no harm. A kinder and gentler society that focuses on empathy and kindness might make a difference in some cases, but by no means all. The most attentive parenting and caring communities may still fall short when it comes to troubled individuals with distorted senses of reality.
In the absence of the ability to meaningfully predict and intervene before troubled individuals act out, whether they have a psychiatric diagnosis or not, we may wish to look to and study those places where violent deaths are far fewer and consider the differences in place. Are these differences those of demographics, politics, economics, values, or perhaps access to firearms? We make many tradeoffs as a society to achieve certain results and goals. Considering and studying these choices in an open and objective manner may be of great value to all.