Back after an internet outage. Miss me? I had been reading a WSJ “consumer choice” panel discussion about what’s known as “Consumer-Directed Health Care” (CDHC), which is, predominantly, a) a waste of money; b) an opportunity to shift risk and responsibility to the sick, and c) a totally ineffective way to go about fixing our health care system. Let me explain.

A couple years ago, Congress allowed “Health Savings Accounts” (HSAs) to be created. They are insurance programs that encourage people to cut down on their health care costs by putting them in charge of their health care spending. For example, maybe your employer puts $2,000 in your HSA. You have $2,000 to then use for all your health care expenses during the year. If you get really sick, once you pay a certain amount out of pocket (your “deductible”), the insurance plan takes over and pays for the rest of your hospital bill.

Now, this makes really good economic sense at first glance. If I make you pay out of your own account to go visit the doctor, you probably won’t go unless you really need to. If I make you pay out of your own account for your prescription drugs, you’ll probably be more proactive in trying to get the generic version, or making sure you’re getting a good price on the medicine, or that there’s not a cheaper alternative out there. But look a little deeper, and you’ll pick up a couple really big (okay, HUGE) assumptions we’ve just made: that you’re currently going to the doctor when you don’t really need to, and that you’re able to tell when you do need to visit the doctor and when you don’t really need to.

Assumption one: Yes, there’s some people that visit doctors “too often.” They’re generally hypochondriacs–myself probably included. But other than that, do you honestly like to hang out at a doctor’s office? With sick people all around you? Do you go just to chat? To have a good time? To skip out of work? I honestly don’t think people do. There are definitely times when people just have a cold, and the doctor doesn’t give them any medication, just tells them to rest and drink fluids and chicken soup. Maybe those are times that a person didn’t need to see the doctor. But see, that brings us to assumption number two…

That being the assumption that you know when you need to see a doctor, and when you don’t. If you know it’s just a cold, or a sore throat, maybe you just pick up some Nyquil and stay home from work a couple days. But if you have some different symptoms, some you’ve never had before, should you go in? Or should you stay home? The HSA or CDHC model puts this choice in your hands. This model hopes to eliminate unnecessary spending , but keep necessary care. I’m personally skeptical that people know how to make the distinction–I sure didn’t before I started working in the hospital.

But let’s give CDHC supporters the benefit of the doubt, just to see where this goes. Say they go to the doctor, and the doctor tells them they have a very serious condition, and really should go to the ER right away. The doctor is very concerned. The patient is college-educated, but knows little about this specific condition. Say the patient goes to the ER, and they’d like to run a test. One test costs $1,000 but may not be good enough for a diagnosis 25% of the time, but it can damage the kidneys and exposes you to radiation. Another test costs $2,500 but will make the diagnosis 90% of the time and is invasive and has a bigger risk of bleeding and death. Which should the patient choose? Does the patient honestly understand the tests or simplified versions of the risks and benefits to make the best decision? Are we as a society going to accept a system where a person chooses to ignore a doctor’s very serious warning because of possible cost? (I guess we already do; you make this decision if you’re uninsured.)

And then there’s the problem of choice. If you’re sick, how much choice are you really going to want when seeking medical care? Maybe a hospital that’s 2% cheaper is 50 miles away. Is it worth the money you’ll save? How do you even know how much you’ll save, if you don’t even know what tests you’re going to have done? Maybe a blood test is cheaper at one hospital, but an x-ray is more expensive at another. Do you hop around between hospitals and doctors’ offices to save money? If not, then how are you saving any money in the health savings account to begin with?

I think I understand what the CDHC folks are saying. If you can give patients incentives to get cheaper health care without compromising quality or outcomes–inquire about generics, for example–I think that’s great. That makes sense to me. But anything more complicated feels like some thin ice under our feet. When you’re healthy, it’s consumer directed health care. When you’re sick, it’s patient burden health care. This all on the heels of study indicating people are more likely to forego care in one of these CDHC plans.

Oh, and I forgot to mention the biggest reason this is a waste of time and money: 70% of all our health care costs come from 10% of our patients–the very, very ill . Attacking a problem (creating more bureaucracy) will hurt more people–the 90%–than it’ll help. Oh, and did I mention 21% of our spending on health care goes to billing ?

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I’ve made some major upgrades to Medslist , the website I developed to allow people to save, edit, and print their medication lists online. You can now edit your list (I know, I know, this should have been there in the first place), and you can also print out a wallet-sized card that lists your medication, dosage, frequency, pill number, and reason for the medication. Go take a look. Any feedback is always appreciated!

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We teach medical students that the reasons for an association or lack of one in a clinical study are: chance, causality,bias and confounding. The fifth factor, fraud, was not typically emphasized in that regard, now it maybe it should be.

Nuff said.

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I saw a patient this week with what my attending and I believe to be some sort of chronic pain syndrome ; I call it a “run-in” because it was so damn difficult and frustrating for both parties–the patient and the doctor.

To be honest, I don’t know a whole lot about these syndromes–just that they’re usually in women, and usually consist of very long-standing pain that is refractory to multiple medications, and often has no etiology we can see on scans. Many times labs will be completely normal, too. These problems usually begin around the time a person has a very stressful life event–loss of a family member or loved one, sexual assault, etc. Then this pain starts, and it won’t go away, no matter what we do. Some people think the pain is psychogenic–caused by the mind–but let’s make it clear: this doesn’t make the pain any less real, severe, or exhausting than any pain with a clear cause. From what I’ve heard, the doctor-patient relationship can be very challenging with patients with these problems. On the patient’s side, he or she may think the doctor is not doing his job, and leaving the patient to suffer. Or he or she may think the doctor doesn’t believe him or her. On the doctor’s side, it’s incredibly frustrating (and questions your ability as a doctor) to have a patient that just doesn’t seem to get better, no matter what you try.

And so it was that I saw Jill . Jill has had chronic pain since 1998, when her mother died and she was emotionally abused at her place of work. She has it down one arm, and it never goes away. It’s now so bad that she can’t sleep at night, maybe getting two hours of sleep maximum. She’s no longer working, and has no health insurance. Jill has been to many doctors, many emergency rooms, and never had any success; her doctors always prescribe her a medication that she says gives her terrible side effects, and which she cannot continue to take. (You can imagine Jill is frustrated with doctors and medical folks, as they clearly haven’t had any luck treating her so far.) They’ve tried valium, ambien, and trazodone, all powerful drugs that should have zonked her out. These didn’t touch her. I ask about other medications she may have tried in the past “Any opioids, like codeine or vicodin? Any drugs like gabapentin or neurontin?” She immediately says, “I’m not taking any drugs. I’m sick of trying drugs. My father was a pharmacist. I can look at any drug and tell just by it’s name that it’s going to have side effects. And that it’s not going to work.” She produces a list of drugs she’s taking, including amoxicillin, a pretty standard antibiotic, for an ear infection. She says that “all these give me side effects.” “Even the amoxicillin?” I inquire. “Yes, that one just gives me terrible side effects.” I ask her what the side effects are, and she says she “can’t even describe them.” My initial instict was to press her to try to find out what her side effects are, but I let it go.

I’ve never experienced this kind of reaction before, but I grow concerned–we’re not surgeons, what else can we do besides give drugs and suggestions for other ways to fix her pain? So I take a step back, and ask Jill, “So what are your goals for this visit today?” She replies, “I want a scan of my head, and I want to get rid of this pain so I can sleep at night.” I say, “Okay, we’re here to help, and we’ll do our best to try to help you today.”

I examine Jill, doing a full neurological exam, and she’s very weirded out when I shine a light in her eyes, check the feeling in her face, and ask her to shrug her shoulders. (Clearly no one has even done a neuro exam on her, gone straight to their diagnosis.) So I go present to my attending, and we go see Jill. We’re kind of at a loss for what to do. We’re happy to refer to the county hospital for a scan, but it’ll take 3-4 months to get. When we come to the subject of her pain, we suggest some medications that she hasn’t tried that may work, but she refuses them all. We say we’re kind of at a loss–we repeat that we’re happy to help, and it’s her body, we can’t force her to take anything–but if not pills, we’re stuck. My attending smartly suggests accupuncture, and she says it won’t work (“that’s only for work-related stress”). She clearly was getting frustrated with us, and we were running out of options.

We left it at that–giving Jill a prescription for a medication that she may or may not fill. She left upset with us, I’m pretty sure. I don’t know what else I could have offered her, especially without health insuarnce, in a free clinic setting. I probably should have directly asked her if she felt depressed or suicidal, as I was reminded later. But what could have I done with that information? She probably wouldn’t take an anti-depressant, and without insurance, she’d be pressed to find a talk therapist. I probably could have referred her for a psych consult at the county center, but she’d already seen a psychiatrist and had a very bad experience again.

I feel terrible for Jill. I have my own chronic pain stuff, but with a visible cause and some decent (but nowhere near acceptable) treatments. If I see a doctor about my problems, he recognizes my problem and gives suggestions. But with Jill, she doesn’t even get that. She gets another prescription and another referral to another doctor, without successful treatment. I almost hope that our scan we ordered finds something–anything at all. Even a blip, some noise, or just a smudge on the monitor. At least then she’ll feel like there’s something there, something real, that she can fight against. For now, though, we don’t know what’s causing her pain, and we probably don’t have anything to treat it.

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