July 30, 2016

I was discussing my current philosophy of life with one of my patients and he asked me if I would publish it. He thought that if his wife could read it, my philosophy would help her deal with her health problems.

The way I see it, the concept of “tomorrow” was created by Satan in order to ruin today. Every morning when I get up it’s today.  Today is a precious commodity.  The only thing I am guaranteed of is this moment.  Recent world events have proven how very transient life can really be.

So, why should I worry about tomorrow? If I spend today worrying about this fictitious entity called “tomorrow,” I waste today.  Can I change tomorrow?  I don’t really know.  I’ve been planning for tomorrow all my life and I don’t think I’ve really accomplished anything other than wasting a lot of days fretting about a future I have no control over.

So don’t ruin today worrying about “tomorrow.” When you awaken in the morning, deal with the issues you can deal with today.  Don’t waste a moment of the “now” worrying about “tomorrow.”  Don’t let Satan win.

The following video on vaccines is well worth watching:

http://www.kevinmd.com/blog/2016/04/a-message-to-parents-worried-about-vaccines.html

March 7, 2016

Dr Lopatin’s article, “Society must decide what it wants from health insurance,” published on KevinMD, is thought provoking and right on the money. Unfortunately, society has very little choice in the matter.

In recent days, I have written articles about the high cost of medications and the problems with “prior authorization.” I have also capitulated as, unlike Dr Lopatin, I have lost battle after battle since January first.  Those battles have been expensive as we have wasted hours of time on the phone fighting for medications that have been ultimately denied, thus reducing the time available to treat the patients who need to be seen.

My suggestion is to stay healthy and invest in your diet and exercise. A healthy individual will not be hurt by our broken healthcare system.  Remember, the life you save by taking good care of yourself may well be your own.

March 5, 2016

Originally published on March 5, 2011, this article ranks in my all time top five viewed publications.  As insurance and Medicare become more restrictive, medical luxuries become more important.  With the recent move to brand many tests and interventions as unnecessary, what was once cutting edge and “necessary” now falls into the realm of luxury.  The statisticians look at what is “enough lives saved” in their quest to define necessary.  PSA screening is no longer “necessary” as not enough lives were saved for the cost of the test.  If your life is saved by a test of intervention, doesn’t that qualify as “enough?”  “Medical Luxuries” addresses the word “need.”

The word “need” means different things to different people.  In an earlier article, I referred to “need” as the new four letter word.  People overuse and abuse the word “need”.  In my practice of medicine, I define three levels of need.

A level one need is critical and worth fighting over.  I see level one needs two to three times a week.  Level one needs are exemplified by the 60 year old hypertensive male who has chest pain.  He needs to be in the hospital now!  He needs to go by ambulance now!  His life depends on it.  When he refuses to follow my advice, I dial 911.  When he is at home and refuses to heed my advice, I call 911 and his wife.  Level one needs are absolute!

Level two is where I spend the majority of my time.  My job is to inform you why you need whatever it is you need, what the benefits and risks are, what the expense is and how soon I think you should get it done.  I then leave it up to you to decide if and when you are going to do it.  I may disagree with your decision but I will respect it.  A routine colonoscopy is the standard of care at the age of 50.  It is a level two need.  (If you have a family history of colon cancer, it is a level one need.)

Level three needs are luxuries and the topic of tonight’s article.  Luxuries are needs you can do without but can do better with!  In medicine, a luxury is anything that is either unproven (but promising), not standard of care, or not covered by insurance.  We live in a peculiar world.  I have patients who won’t get a chest x-ray ($200) because their insurance won’t cover it.  They drive to the office in a BMW but won’t spend $200 on their own health.  I have patients who eat at expensive restaurants every weekend ($50 per person) yet want an inferior generic because the branded cost is $100 per month.  The insurance world has convinced us that if, they won’t pay for it, either you don’t need it or it is too expensive to afford.

Luxuries can save you money and your life.  Several years ago, I was called in to the hospital to see a very sick patient at 5 a.m.  I dressed quickly, jumped into my car, backed out of the garage and slammed into my daughter’s car.  I had not spent the extra money to buy back up sensors when I purchased my car.  My decision had consequences.   I had to tell my daughter I smashed her car.  I had to pay for her repairs, as well as mine.  What seemed like a luxury item at the time turned out to be more of a necessity than I had anticipated and a costly error in judgment as well.  Luckily, the patient did fine.

So what are luxury medical items?  The Heart Check America (Cardiac Scoring) is a good example.  It measures the calcium load in your coronary arteries and predicts coronary artery disease.  A healthy 50 year old male with no family history of heart disease is buying a luxury when he gets one.  Insurance won’t pay for it and technically he doesn’t need it.  So why get it?  Most of us are healthy until we are not.  If his results are normal, he gets peace of mind.  If his test is strongly positive (it happens to the healthiest of us), he may well have saved his life.

Every year there are unexpected deaths in our community.  Could the purchase of a healthcare luxury, an annual physical, an EKG, blood test or x-ray, have saved their lives?   I would like to think so.  The next time your doc asks you to get a test or buy a medication that is not a covered benefit, think twice before you dismiss the idea.  Times are tough and money is tight; but, if your roof was leaking, you would find a way to get it repaired.  I often use analogies to make a point and my favorite has to do with your house.  Your house is very important; and, when it needs repairs, we find the means to do so.  Your house shelters your body; your body houses your soul.  Do everything you can to protect your body and keep it fit for many years to come.

“A start medical student feels like he made a terrible decision” published on KevinMD by ANONYMOUS just makes me want to cry.

From the time I was 13 years old, I told my doc, Jerome Perlman, that I was going to go to medical school and be his partner. When I first brought up the subject in 1964, Jerome told me that the world of medicine was changing and the changes were not good.  I ignored him.

When I graduated from The University of Virginia, I told Jerome I’d join him in 7-8 years. Jerome again told me that the world of medicine was changing and the changes were not good.  I ignored him.

When I graduated from medical school, I called Jerome and told him I was one step away from joining him. Unfortunately, Jerome had to retire before I could join him in practice.  His parting words echoed his thoughts from the past, “the world of medicine was changing for the worse!”

Jerome was right about a lot of things. I have strived to emulate this great man.  I only wish that he had been wrong about the world of medicine’s demise.  Despite the demise of my profession, I’m still glad I ignored him!

March 3, 2016

I was listening to Hillary address a crowd of supporters the other day. She talked about “empowering” people and her promise to stop the injustices in our society.  The more she talked the angrier I got!

“Hillary Care” was the beginning of the downfall of my profession and Obamacare, the final nail in the medical professions casket. I’m amazed at how both Hillary and Obama have, in fact, empowered the insurance industry while crippling the medical professionals ability to survive and function.

Today, I received a letter from a cutting edge, national laboratory. They closed their doors due to “adverse changes in the regulatory environment, increased pressure from commercial insurance payers and continued compression of profit margins.”  This is the second closure of a laboratory that has provided valuable information for my patients in 12 months.

Yesterday, my nurse brought me a pharmacy benefits manager’s letter refusing to pay for a crucial medication that my patient has taken for the last 10 years. Since January 1, I have informed hundreds of my patients that their insurance company will not pay for their medications.

Unfortunately, denial of service has become the usual in my world. Insurers refuse to authorize testing or make the process of prior authorization so onerous that I really have to think twice before subjecting my staff to mountains of paperwork and hours of frustrating wait times as the insurer parks them in a purposely lengthy queue.  If you think I exaggerate, Ewa has a 3-inch high stack of denials on her desk covering a month of trying to get a new cholesterol medication approved for five patients who have failed on all other treatment options.

Yes, since Hillary started this mess years ago, my tool chest has shrunk considerably. Since January of this year, my patients and I have lost many of our healthcare battles and surrender to a system that continues to grow in power daily.  And yes, I too fear that the day when my doors close due to “adverse changes in the regulatory environment, increased pressure from commercial insurance payers and continued compression of profit margins” is coming.

I am dedicated to providing the best of medical care to my patients on an individual basis and keeping my doors open to all who need my care. I am also getting pummeled daily and slowly being stripped of my independence.

I wish I could tell you that help is on the horizon. Our political madness guarantees that it is not.  The best you can do is take good care of yourselves.  Exercise regularly and eat healthy foods.  Enjoy life to its fullest.  For me, it’s time to go to the gym!

February 25, 2016

It’s time to start writing again. The American medical system continues to change rapidly and those changes affect the care you receive. First, let me say that I believe my profession has died. Doctors have become human service technician and medical clerks. It’s sad but true. My kind of doc is soon to be extinct.

The article listed below and published on KevinMD today is excellent. While Dr Bowron’s article addresses the concerns of hospitalists, their concerns and problems are universal.

“Am I a health care business metric or a physician?

Craig Bowron, MD | Policy | February 24, 2016″

For those of you who do not have the time to read the entire article, there are two paragraphs that I think are particularly important. The first:

“There’s a romantic yet antiquated notion that doctors are at the peak of the health care pyramid. But it’s the MBAs — some of them with MDs — who are in charge now, and the business of health care demands what every other business demands: ever-increasing efficiency. We must all do more with less. Ostensibly this will lower health care premiums for everyone — or just increase profits for the health care industry.”

Medicine was never supposed to be a business. Medicine was a noble profession when I started in 1980. It is most definitely a business now with all the profits going to the one percent at the top of the management structure. Those of us in the “caring division” are suffering, trying to deliver good care with dwindling resources.

The second important quote is:

“What will never be part of the system is the sacred space that I and an ailing patient occupy when I pull a chair to the bedside and commit all of my energy, education, and humanity to listening to and deciphering his or her story. Because becoming ill is a story, an intensely personal one. When we are sick, we descend into our most primal human state, surrounded by the surreal and vulnerable notion of our own mortality, confronted by the fact that the only “skin in the game” any of us has is our own skin.”

Dr. Bowron couldn’t be more right. Unfortunately, I fear his kind are soon to be extinct.  In the corporate world of medicine, one is forced to sit down by the computer and interface with its screen and keyboard leaving precious little time to hear anything other than the clicking of the key.

How sad reality has become!

Pharmaceutical Manager (PM)

February 24, 2016

Dear PM,

I’ve known you for years. We’ve been the best of friends.  You’ve brought me miraculous medications over the last 32 years and helped legions of patients enjoy longer and healthier lives.  In many ways, you’ve been a knight in shining amour.

It hurts me to say this, but you’ve been bad lately: really bad!  You’ve priced your medications so high that the average patient can no longer have them.  Your antidepressants eat up so much of a patient’s budget that it is depressing!

I know that there are many factors contributing to the outrageous cost of your most miraculous medication. I’ve previously written about the cost of liability insurance.  I know that the cost of bringing a new medication to market is massive.  I also know that your need to increase your corporate profits has led you down the wrong path!

As your friend and longtime admirer, I’m telling you it’s time to change your ways. It’s time to scrap the sample and discount card programs and reduce the upfront cost of your medications.  Everyone is coming after you.  You are Hillary’s villain.  She openly avowed that she was coming for you in her last debate.

The PBM (Pharmacy Benefits Manager) is your avowed enemy and they are all powerful.  They simply are denying access to your medications. You are the patients’ avowed enemy.  They see you, not as a knight in shining armor, by as a greedy pusher who has what they need but demands their life’s blood to purchase it.

Just how much do you spend on those Viagra commercials? Discount cards? How does a medicine that sells for nine dollars in Mexico, sell for fifty dollars here?  Why is a medicine that costs eight Euros sell for eighty dollars here?  As your friend, I’m telling you it’s time to think out of the box and sell more units for less, here, in the US.

As your friend, I’m warning you. My patients are fed up.  I’m fed up!  Time to buff up you armor and get on your stallion and rescue us!

Pharmacy Benefits Manager (PBM)

February 23, 2016

Dear Mr. PBM,

You win! I can’t fight you anymore.  You are powerful; and, since January, you have been flexing your muscles and crushing all that dare to challenge you.  I’m beaten and despondent.

You refuse to pay for lifesaving medications. You refuse to pay for medications patients have been on for years.  You refuse to pay for anything branded and now you even refuse to pay for many generics.

You demand that an appropriately treated and well controlled patient previously suffering from depression give up his medication for one that you approve of. It doesn’t matter to you if my patient relapses into his prior depression.  You don’t even try to justify your actions.  You state that you aren’t denying my patient the right to his medication.  You say he can pay for it himself. He can’t.

You’ve helped drive up the retail cost of his medication. His financial situation is one of the many factors contributing to his depression.  You’ve left him no choice.  You’ve left me no choice.  He will change medication.  He may suffer a relapse.  You, on the other hand, will please your stockholders.  You may even get a bonus at the end of the year.

You’re stifling innovation. You refuse to pay for a new, novel cholesterol lowering medication that can help those patients that cannot tolerate statins.  I’ve tried to prescribe it to 5 patients and you have denied five requests.  We have filed piles of paperwork trying to get this potentially lifesaving medication approved by your minions.  You have rejected everyone.  We have filed multiple appeals, all denied.  My staff has invested hours of work costing me lots of money to no avail.  You win.  I won’t prescribe this medication again.

You’re increasing the cost of providing care in multiple ways. You don’t care.  My patients will be referred to a preventative cardiologist at a major university hospital.  Maybe he can succeed.  Maybe he won’t.  Maybe one of these five patients will have a heart attack while he/she waits for this medication.  Maybe they will use this article to sue you.  I hope so!

You are so sure of your power that you even refuse to pay for cyclobenzaprine, an old generic that retails for 50 cents a pill. You win!  You are an insurance company that, while increasing your rates yearly, cuts expenditures regularly.  Yes, you are powerful.  The devil usually is; and, unfortunately, in the real world, the devil wins!

It’s no wonder so many docs commit suicide every year! Fighting the devil takes a toll on you.

February 14, 2016

Whose fault is it? The cost of medications has finally reached unacceptable levels.  Every day patients come in requesting changes in their medications as they can’t afford to buy them.  No matter that they need their medications or that their medications are lifesaving pills, they simply can’t afford them.  Whose fault is it?

The other night, I was watching the Democratic debate and Hillary proudly announced that her “Hillary Care/Obama Care” was tackling the pharmaceutical industry. Are the companies that make your medications at fault?  I used to think so but I no longer believe it.

I just got back from Mexico and was both shocked and pleased to find that Voltaren Gel, a non steroidal anti-inflammatory gel I use for my aching joints, was on sale for $9 a tube. The cheapest I have ever seen it in the US is $50 a tube and most insurance companies require a mountain of paperwork before they will even consider paying for it.

Novartis makes Voltaren Gel; and, other than the Spanish words on the box, the Mexican and American products are almost identical. So, if the pharmaceutical companies are the villains driving up the cost of our medications, why isn’t Novartis charging $50 a tube in Mexico?  Remember, I said that the Mexican and American versions were almost identical?  Could the difference in the accompanying paper inserts account for the higher cost of the American product? I think so.  Let me explain.

The American product comes with reams of enclosures: paper from the manufacturer, the doctor and paper from the pharmacy that fills it.  There are detailed instructions and even more detailed warnings.  The Mexican product does not.  Apparently, Mexicans can figure out how to apply the gel and that it is not a suppository or eye drop and Americans can’t get it right.

In reality, all the documentary inserts are instructions that are designed by attorneys to protect the pharmaceutical company, doctor and pharmacy against lawsuits. These papers are scrutinized and approved by the FDA and then are reviewed by trial attorneys seeking to win the lottery by suing all parties involved in the care of a patient.  There is a cost to the legal system in this country and I think these legal costs are what are driving the cost of your vital medications through the ceiling.  The result is that, while all the rulemakers are “covering their backsides” with legal mumbo jumbo, the price of this protection has made your medications unaffordable despite their critical role in keeping you healthy.

Have you seen the law firm’s commercial on TV where the actor says that the manufacturer of Plavix has settled a suit for $650,000 and you or your loved one may be owed money? Who do you think pays that $650,000?  You do!  You pay for every outrageous suit filed in a US court.

You pay when you buy a chair, a car, food, pharmaceuticals, etc. Manufacturers and owners of businesses pay liability insurance and the cost of that insurance becomes overhead and the cost of overhead is passed to the consumer.  Let me get back to the cost of your medication.

Why aren’t the candidates for the presidency talking about tort reform (according to Wikipedia, “Tort reform refers to proposed changes in the civil justice system that aim to reduce the ability of victims to bring tort litigation or to reduce damages they can receive”)? Could it be because they are attorneys?  Perhaps the contributions that the trial attorneys’ lobbies make to the candidates’ Superpacks really do influence their judgment?  Whatever the cause, something has to change.

Unfortunately, what is changing is my patients’ health. They are going without their medicine or seeking cheaper, less effective alternatives.