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Patient: I can’t afford the insulin you prescribed for me.

Me: It’s a pretty standard long acting insulin

Patient: My insurance says it’ll cost $350 a month to use it, is there something less expensive?

Insulin is a magic drug. Discovered in 1921, it was first administered to humans in 1922. Although there were a long line of discoveries that made the discovery possible, Drs. Banting and Best at the University of Toronto were the first to identify the source (the pancreas) and to extract insulin for use. Even more amazing, the University made the discovery “open source,” allowing the manufacture and distribution without royalty.

The discovery was not without its problems. Although human insulin was synthesized in the lab, it was difficult to make for many years. Insulin taken from cows and pigs was commonly used clinically. Unfortunately, in one of the Creator’s little jokes, these insulins vary from human insulin by a couple of amino acids. Not enough to make them unusable as extracted but enough so that over time the diabetic patient developed antibodies and was unable to use the insulin, leading to his or her premature death.

In 1982 Richard diMarche and Eli Lilly obtained a patent for human insulin made from recombinant DNA. Originally sold as Humalog, this was the first medication manufactured in this manner and it was a game changer. No longer were we putting a foreign body into people to lower their blood sugar temporarily. We were putting human insulin into people and keeping people alive longer and keeping people healthier.

Which brings us to today. Drug companies developed pens, different types of insulins, and different delivery methods. They have also jealously guarded their patents, preventing cheaper generics from being developed. To quote the New England Journal:

“But whether each incremental innovation is worth the price we pay, in a world where insulin remains unaffordable to many patients with diabetes, is less certain.”

Reasons used for the high cost might include the need to ship the medication in liquid form as well as the different delivery mechanisms. The bulk of the cost of the drug, however, is in R&D. These drugs have been developed for years and there are no more R&D costs. Their investment has been recouped. It is becoming clear that a major reason is good old-fashioned “profit taking”:

Between 2005 and 2015 the cost of a lispro vial went up 264 percent, while a vial of insulin glargine went up 348 percent, and a vial of NPH went up 364 percent. That’s a lot, but other insulins went up even more.

The cost of an aspart pen rose in this 10-year period by 389 percent. And the cost of a vial of U-500 regular insulin jumped a staggering 508 percent.,


So, in America in 2016 we have people choosing between insulin and food. People that weren’t having to do that in 2006. The speculation is that this profit taking is in advance of the loss of the patent as well as the lack of “blockbuster” drugs on the horizon. Perhaps generics will be developed soon.

What did I do for my patient? There is one type of intermediate acting insulin that is $27 a vial at Wal-mart. No special pen, has to take it twice a day. For now, it turns out that diabetes in now a two-tiered disease, easy for the rich to handle but increasingly difficult to manage if you are poor.



Samuel Shem, House of God (Quoting the Fat Man’s Laws)

On rounds a while back in the hospital, we had a patient who had come from ICU and was being cared for by our team. He was a little older than our average patient (he was in his mid 80s), a little sicker (his kidneys and liver were failing), and a lot scared (I don’t want to die, doc. I want to feel better. I want to go back to how I was. Don’t let me die). He was getting a lot of blood draws, had a catheter in, and was getting IV fluids and a strong diuretic. Thanks to “big data” we now have calculators that we can plug in certain data and determine the likelihood of the patient being alive at 3 months, 6 months, and a year. In this patients case, there was a 50% chance that he would be alive in 3 months. As much as I wanted to, I was not ever going to be able to put him back together. I was also sure that he would have at least one or maybe two more trips to the ICU before he died. The sad thing is, those trips to the ICU might just cause him to die sooner.

Americans have believed that the US Healthcare system is the best in the world despite the fact that we consistently rank last among wealthy countries in almost every category measured. We are the most expensive in the world, spending twice what the next highest country spends.. It appears, that we have mistaken excess for quality. It also appears that we physicians are complicit in selling this belief to the public.

I often have patients say to me “do everything.” Often, they make that statement as the end of life is rapidly approaching. In this country, everything comes with a steep price-tag. Part of that price is monetary, For example we spend $1.25 billion in Medicare recipients for cancer care with 25% of that occurring in the last month of life. Part of that price is in shorter life-spans (from the Dartmouth Atlas):

Ironically, research has found that in patients with chronic illnesses, more aggressive interventions result in shorter life expectancy, probably because of the risks associated with hospitalization. This indicates that the best strategy for extending the life of people with chronic illness is to focus on those activities that provide a survival benefit – better control of blood pressure for people with diabetes, for example – rather than on “heroic” end-of-life care.

It turns out that the Fat Man was right. For a lot of people, symptom management (What would you like to be able to do?) with the reduction of aggressive care actually leads to a longer, better life.

What can you do? Take advantage of being well and determine what you would like others to do for you when you are sick. The CDC has some good information on advanced care planning. Only 20% of Americans have done so. If you suffer from chronic illness, have a conversation with your physician about what your expectations are regarding your last year. Only 25% of physicians report having such a conversation. Limit your care seeking behavior to what really is necessary. One in three Americans who die have seen over 10 physicians in the last 6 months and yet they still died (and perhaps sooner than they might have). When it is clear that a cure is not possible, seek symptom relief. Programs providing palliative care improve length and quality of life. In Alabama, only 20% of hospitals have such programs. Makes it hard to follow the Fat Man’s advice.

The market has not worked to attract people to rural America to care for our rural citizens (a topic for another day). After doing some research for a talk, it turns out that health care professionals are actually responding appropriately to the market:

Rural residents seeking health care are (as a rule)

  • older than urban residents
  • in poorer health than urban residents
  • more likely to be disabled
  • more likely to be uninsured
  • more likely to face financial barriers in obtaining healthcare
  • more likely to incur travel burdens while seeking care
  • much less likely to receive services than are their urban counterparts if they suffer from serious mental illness. There are specific barriers to mental health access. These include
    • Service fragmentation
    • Lack of transportation
    • Lack of cultural and linguistic competency
    • Poor rates of Medicaid enrollment among people with mental illness
    • Stigma associated with mental illness
    • More poor immigrants

 The south offers more complex set of problems that make the market even less likely to be effective

  • Population is in decline and poverty is increasing in rural areas
  • Rural poverty tends to be persistent, historically complex, self-perpetuating, and psychologically and culturally oppressive
  • One third of the poor in the United States live in rural areas, and the rate of poverty in rural counties is increasing at a faster rate than it is in urban areas
  • Residents of rural counties in the south are more likely to be unemployed, less likely to be Medicaid eligible

All in all, President Obama’s vision, as articulated in his speech on Wednesday, said very well why we need to work to care for our fellow citizens despite there being no profit:

But there’s always been another thread running through our history – a belief that we’re all connected, and that there are some things we can only do together, as a nation.  We believe, in the words of our first Republican President, Abraham Lincoln, that through government, we should do together what we cannot do as well for ourselves. 

And specifically about healthcare:

We recognize that no matter how responsibly we live our lives, hard times or bad luck, a crippling illness or a layoff, may strike any one of us. “There but for the grace of God go I,” we say to ourselves, and so we contribute to programs like Medicare and Social Security, which guarantee us health care and a measure of basic income after a lifetime of hard work; unemployment insurance, which protects us against unexpected job loss; and Medicaid, which provides care for millions of seniors in nursing homes, poor children, and those with disabilities.

My wife and I were invited to dinner at the home of one of my daughter’s friends. My daughter is a graduate of the International Baccalaureate program of Murphy High and her friends tend to be interesting (if not a little nerdy). This particular friend is majoring in pre-med and has parents who immigrated from Vietnam following the fall of Saigon. As is usual when one has a physician dinner guest (and perhaps when one doesn’t) the conversation turned to mutual acquaintances and the interactions they have had with the health care system. One particular discussion, although I have changed  the circumstances a bit, illustrates one of the concerns that I have with health care reform.

The story was about a mutual acquaintance who happened to be Vietnamese and had an untimely death. He was not cared for by me or any of my close colleagues so the circumstances always remained a little unclear to me. The word in the community was that he had been feeling poorly for a bit before his death. My host reported that he went to seek medical care (“all he saw was his family doctor”), was placed on some medications, and later died. As the conversation progressed, other speculation was that he may not have taken the medication (Vietnamese don’t like to take medication if they don’t feel badly) and he otherwise may not have been a full participant in his care (western medicine is too strong). My hosts, who speculated that cardiac disease was the cause of his death, implied that if he had only seen a cardiologist things might have ended differently. I have to admit that part of me had a pang of regret as well…

The problem is communication. The pre-patient attempting to interpret his or her own symptoms (are they bad enough to seek care, who should I seek care from, if I don’t feel better) is often discouraged from easily communicating with a live human being who could assist with this interpretation. As it turns out, up to 58% of all Americans use the Internet to determine how and when to access other health care resources. This resource, while offering the world’s information, does not facilitate personalized interpretation. This particular person’s health symptoms were made more difficult to interpret because of the circumstances (when you survive near starvation in Vietnam living on cassava you don’t complain about a little chest pain) and residual health beliefs brought in from a previous culture (well documented by Anne Fadiman in “The Spirit Catches You and You Fall Down”)

How could this have ended differently? Maybe not at all, as people die of heart attacks all the time. If it were to have ended differently, it would have been as the result of an improved interface between the person who might be sick and the health care system. The Advanced Primary Care model offers one such model. The patient would be in a relationship with a TRUSTED Family Doctor (or his or her staff) who could help with personalized symptom interpretation prior to becoming ill. Second, this TRUSTED Family Doctor will be able (by virtue of a changed payment structure) to take sufficient time to determine if there are special needs (communication, residual illness beliefs, etc) that would need to be dealt with at the time of a visit or while engaged in other types of communication. Thirdly, this TRUSTED Family Doctor will be willing to work with the patient to overcome these barriers and facilitate optimum care NO MATTER HOW LONG IT TAKES.

Obviously, I feel strongly that we can and should be practicing in this manner. Why do we not? First, I believe that we as a country have a love affair with technology and feel more comfortable relying on specialist-controlled technology for symptom interpretation in the same manner that we like the mechanic to “hook the car up to the computer.” Trying to convince the average person that a “Level 1 Diagnostic Scan” is worse than worthless is going to take  a lot more than me saying so. Second, spending time with the patient is not why doctors currently get paid. Insurance companies have been quick to reward doctors for using technology (under the mistaken belief that it would make the system more efficient) and have been slow to develop ways to reward extended interviewing and risk analysis based on multiple methods of information gathering. Third, I suspect we admit students into medical school who prefer interacting with technology to people interaction. Insurance reform has happened. Now lets discuss real health care reform

Forgive me as I yell at the Press Register. Deroy Murdock’s syndicated column (you can find it with Google, I’m not going to help) either provides talking points to conservative talk radio or takes marching orders from conservative talk radio and is carried in the Mobile newspaper this morning. In it, he misrepresents  an analysis of the current health care legislation done by the Health and Human Services Chief Actuary. A misrepresentation that is, oddly enough, consistent with Republican Leadership and Talk Radio News. Following is the ACTUAL conclusion:

  • 33 million more people would have REAL health care access (not just access to Emergency Departments if dying)
  • Medicare and Medicaid would probably COST LESS
  • Total health expenditures would increase transiently as more people get coverage
  • Long term care would probably cost more than estimated
  • The effect of comparative effectiveness research is unknown.

It’s just a lot easier to defend a deeply held belief if you are able to avoid facts, I guess.

I’m in correspondence regarding the concept of Advanced Primary Care with someone from a rather large corporation who feel that the senior executives are having trouble distinguishing or telling the difference between a medical home and a the old HMO concept of primary doc being the gatekeeper in terms of who picks the specialists and asked id I can you help explain the difference.

It strikes me that the difference is both one of attitude and a new emphasis on evidence based care. From the standpoint of the HMO, the insurance company dictated the “panel” based on who would accept their fee schedule and paid PCPs not to refer. The “advanced primary care model”, depending on how it’s set up, allows the patient to go see anyone (no reward for denying service) with several caveats. 1) The specialist must provide outcomes to the primary care office. Meaning, if you are seeing the specialist for a blocked carotid artery, the Primary Care doc should have a list of who does good work, bad work, or “kills people” work and you get to pick. 2) The patient must be willing to work within the “advanced primary care model” to accomplish outcomes. It turns out that it isn’t about one doctor but it’s that the patient is seeing several doctors who’s area of expertise overlap. All of the data needs to go to the “advanced primary care” practice, who will share that info with all of the other doctors. Most people think that happens, anyway. If one doc is unwilling to share then that doc is not referred to but would you really want to see that person anyway? 3) Typically, a lot can be done in the primary care office. Some plans pay a differential to the specialist if they accept someone on referral vs seeing people off of the street. In that way I can catch the person who needs their lipids checked while taking their skin tag off and give them a flu shot. If they want to see the dermatologist, they can, but at a higher out-of-pocket cost

I was sent a video on Health Care Reform that did an outstanding job of identifying the issues that our country is struggling with. It starts, interestingly enough with the story of Walkin’ Tall, the prise winning pig at the Indiana State Fair. Turns out the pig is unable to walk due to his weight and the author points out that the choices ar to kill the pig, put the pig on a diet, or continue to feed the pig and carry it from place to place. This is, as it turns out, a metaphor for healthcare. As is pointed out in the video, what we Americans chose do with our “pig” depends on how we view our responsibility to our fellow citizens. In the video, the question of healthcare as a right versus a privilege is addressed. The view of the author is that though we view it as a right (EMTALA) that we choose not to pay for directly, which is why we have such a convoluted system of getting folks paid when compared to our fellow citizens of the world.

 Now that all of the bills are out of committee, it is clear that Congress is a reflection of America. We continue to debate what should be included in a health care package for all Americans. Jon Kyl does not, for example, want to pay for maternity care that he certainly will never need. He is a Senator from the state of Arizona. If you are white (as Senator Kyl is), pregnant, and live in Arizona, your baby has a 6/1000 chance of dying in the first 30 days of life (Kaiser Family Foundation). Although access to prenatal care may not make all of the difference, it likely would reduce this even further as we as a country are 5.7/1000. If you are non white, non hispanic your chances of having your baby alive at the end of 30 days in Arizona is 1.2/100. Senator Kyl may want to rethink his willingness to pay for care for people unlike him if he’d like for the infant mortality of these citizens to be better that the Russians (1.1/100).

Kill the pig, feed the pig, or put the pig on a diet. We as a country will need to decide which strategy to follow. Continuing to feed the pig, some say, will result in further economic decay. Others say the “health care sector” is an important part of the economy. Maybe we need to switch to soy bacon.

Cartoon20090812As I watch the post speech debate on what “health insurance reform” really means, I am reminded of the “Sultans of Swing” lyric by the group Dire Straits.  On the one hand, “the most interesting health care consultant in the world”, a Canadian PhD named Steven Lewis, has posted a very watchable video which points out flaws in the comparison of the Canadian system to the US system and makes a strong care for the advantages of “single payor”. I guess as a fan of Dan Aykroyd and Michael J Fox it shouldn’t surprise me that Canadians could be funny and serious.

In this country, however, the competition in the marketplace of ideas is not coming from the Canadians. It is coming from the Republicans as illustrated by the March on Washington yesterday organized by a group called FreedomWorks. Led by Dick Armey,  near as I can tell they are against lawyers (who isn’t  unless you need ’em) and for allowing “competition across state lines”. Not being a particular fan of the company responsible for 90% of the commercial policies in the state of Alabama, I thought this last idea might have some merit, until I looked into it further.

John McCain brought up the idea of competition across state lines in the 2008 presidential election.  I have to admit, it kind-of appealed to me. Since he didn’t win, I hadn’t thought too much more about it until now. It seems simple (why not let Mississippi Blue Cross into Alabama), American (companies should compete), and would seem on the face of it to produce lower costs.

The New America Foundation did not think any of those things would come to pass if “reform” took this guise. A non-partisan group, they looked into this policy change in October 2008. What they speculate would happen given the current state of regulation would be a race to the bottom. States that do not mandate such “luxuries” as emergency care, maternity care and pediatric immunization and prevention would quickly become the home state for many insurance companies so employer based policies would become less comprehensive. There would be even less types of policy choice under such a system. Integrated systems that we are striving to emulate such as Intermountain Health Care, Group Health Cooperative, and the Mayo would have their survival threatened as employers raced to the bottom. If employer coverage were not encouraged through tax policy, the number of uninsured would rise as insurers developed means to exclude high risk individuals and risk pools would become prohibitively expensive.

On the other hand, the foundation feels it could function with guaranteed issue (you get a policy no matter what your risk history is) and federal regulation of health insurance (back with the Stalin pictures), reforms such as are proposed for the “health care cooperatives”. Dick Armey has made his position clear on these addendum to his conservative policy position

“The only thing ‘guaranteed issue’ guarantees is more expensive health insurance and more government involvement. Imagine if they did this to restaurants—if restaurants had to serve dinner to everyone who wanted it (guaranteed issue) from a longer menu (to qualify for the national exchange) at the same price (community rating). The feast would be great—except that all the restaurants would close shop before I got dessert.”

What it comes down to is this: do we as a country see ourselves as having an obligation to provide for basic health care for our citizens? Do we see health care as a privilege along the lines of a restaurant meal? If it is a privilege, are we willing to allow the consequences of denial of care that we know would improve the well being of a fellow citizen because they have not had the good fortune of working for a company that supplies health insurance? Are we willing to do that while we gorge on excessive medical tests, medications for erectile dysfunction, and allow our physicians to make over $1,000,000 annually as they reassure us that America has the best health care in the world?

"Bending the curve" from the Commonwealth Fund

"Bending the curve" from the Commonwealth Fund

In late 2007, the Commonwealth Fund published a paper entitled “Bending the Curve“. The point of the paper was that given the current trajectory, health care expenses will exceed our country’s ability to pay, leading to insolvency. Although this has been the worry of policy makers forever (what’s a good amount of money to spend onhealth care? 5% of GDP like England? 12% of GDP like Canada? 16% of GDP like the US?) and previous policy was that health care jobs were to take the place of manufacturing jobs, increasing our GDP. It turns out that there is an optimum amount to spend if the objective is to achieve optimum health with the least cost possible. That amount seems to be less than what we spend.

The report does not mention rationing at all. Many of the concepts in the report were included in HR 3200, which does not mention rationing either. What is mentioned is “medical effectiveness”, improved health information technology, and shared patient decision making. Using these three concepts, physicians can help to bend the curve down, eliminating the need for hard rationing.

Improving information regarding medical effectiveness should lead to a reduction in use of expensive, unproven technology. We Americans have a fascination with technology. In fact, part of the utilization of the emergency room by patients is because of a belief that technology is necessary for effective diagnosis and treatment. Hospitals in rural Alabama hired physicians away from their practice and had them move into the Emergency Department, subsidizing thier salaries, because they knew that would help attract patients into the hospitals who would then be referred into the technology areas (CT scans, MRIs, etc). Unfortunately, the use of this technology has not translated into people doing better (they may feel better having seen their insides but it is an awfully expensive placebo). Most insurances will pay for technology because there is limited evidence to indicate when technology is good (avoiding an unnecessary surgery) or when it is bad (finding something that is likely normal but “might be something bad” causing excessive worry and unnecessary procedures). In fact, some procedures (placement of stents in certain patients) are found to be harmful after years of having been done. Evaluation of all procedures ought to be more rigorous and establishing money with which to do this will ultimately reduce costs.

Improved information technology (already funding through the stimulus package) should help to reduce costs as well. Transferring information by snail mail and fax is the rule in health care rather than the exception now. Electronic transfer of information, with appropriate safeguards, has revolutionized the banking industry (so much so that the regulators unfortunately got lost in the shuffle). Making information easier to transfer will reduce waste and duplication.

Lastly, encouraging shared decision making is probably the most important of the three. As a physician, I get paid for time in a piecework fashion. If I need to have an hour conversation with a patient about prognosis, different treatment options, or longterm care decisions, I have to schedule it outside of my normal patient care hours and do not get paid at the same rate I would for seeing “regular” patients. Yet, this is probably the most important conversation I will ever have with a given patient. It has been my experience that when faced with a disease that is terminal or that there are several different treatment options, what people want most is someone who knows a little about them to help guide them to a decision they will be comfortable with. All too often, we in medicine assume that the patient always want more and wish to cling to every last second of life but often it is the physicians who impart their worldview instead of listening to the patients and their families. Additionally, the primary care physician, the doctor who knows the patient the best, is often not involved in these conversations at all for a number of reasons. Changing the payment structure will go a long way towards inclusion of the primary care doctor in these discussions.

It is the belief of the Commonwealth Fund as well as myself that these measures will “bend the curve” down without hard rationing. We may have a chance to find out.

There in an article in today’s Press Register touting the opening of several “Urgent Care” centers in the Mobile area. The writer presented this as a huge plus for the healthcare consumers as they could have their “deep cuts” or “sinus infections” cared for in a more timely fashion than in the traditional emergency room. Aside from the more mundane concerns of whether we need a center for this type of suturing (realistically you can do this in between patients in an efficient emergency department as you wait for MVAs to roll in) or sinus infections (think antibiotic resistance), the real issue is one of efficient and effective care delivery. These “centers” are part of the problem. The New England Journal of Medicine has had a series of “Perspectives” about the health-care system in this country. Last week, the essayist compared our countires experience with that of others. As we are all now familiar, we spend twice as much per capita and have much poorer outcomes than all other industrialized countries. In this weeks NEJM, Victor Fuchs points out three “inconvenient truths” about health-care. The first is that the annual growth will lead to healthcare consuming 30% of the GDP within 30 years, an unsustainable expenditure of public dollars for what is mostly (in the case of the American health-care system) a private good. The reason for this growth (Truth 2) is increased access to technology and healthcare infrastructure regardless of incremental cost/benefit to the individual patient or society. Truth 3 is that sick people tend to be poor and well people have to pay for sick people. To quote Dr Fuchs “No country achieves universal coverage without subsidization and compulsion, but U.S. politicians tie themselves and the health care system in knots by proposing reforms designed to conceal these realities. Politically, the most appealing plans are those that mislead people into thinking that someone else is paying for their insurance. Currently more than half of insured Americans obtain their coverage through employment, and workers have been led to believe that their employer bears most of the cost of their care — a belief that labor-market experts have concluded is invalid. When a firm pays $3,000 to $7,000 per worker per year for health care, it can get that money in only three ways: reducing potential wage increases, increasing prices for what the firm sells (which means lower real wages for workers everywhere), or lowering profits.”

The illustration at the top of this post identifies 15  necessary interventions to get control of our health care costs. Many of them involve reinvigorating the primary care infrastructure in this country. None of them identify “increased urgent care access” as the answer. Even though our newspaper doesn’t get it, I hope that the policymakers do.