After a 2 year hiatus I am returning to the blogsphere in order to expiate my frustration at not expressing myself in written language. The proximate reason for doing so that I am reading Jon Meacham,s book : The Art of Power; the life of Thomas Jefferson. This is a significant work that I highly recommend anyone interested in romance, history, Jefferson, or gifted writing. Jefferson left a legacy of his thoughts through the copious letters he wrote to friends and romantic acquaintances. Remarkably much of this writing has been preserved and Meacham has done an incredible job of collating these works into a history of  the US as well as a history of a great leaders life. I do not know how muchpf this is romanticized, but it has charmed me and captivated my imagination. And so it begins that I wish to communicate thoughts, though in no way to be compared with Jefferson or any other accomplished writer, to be preserved in the cloud.

While my past writing was often social as well as medical in context, I trust this writing will be more social and interpretive of my own thoughts in the present. Regardless of how I evolve I reserve the right to change my mind, regardless of whether the facts change or not. Should anyone choose to go on this ride with me I hope it will at the least be entertaining.

Til then ...

The Wealthy vs The Middle Class Drug Insurance Pla

And now we come to the second part of our story: the two-tiered system of mandated allowable prescription drugs. Actually this is a multi-tiered system as each insurer is legally able to create its own list of approved drugs (two tiered refers to drugs the more wealthy can purchase through their insured prescription drug plans vs less wealthy people who have more restrictive plans). What all of these approved lists have in common is cost control, with minimal regard for patient care. What all of these approved lists have in common is disrespect for doctor prescribing decisions. What all of these systems incorporate is an appreciation that young doctors tend to prescribe more costly, newer drugs most often determined by an educational system that indoctrinates doctors-in-training to believe that newer is better. What all of these systems incorporate is a realization that patients come to doctors with a belief that what is newer is better. “Is the new medicine stronger than the old one?” asked the patient. “The new drug is different from the old drug and stronger may not be better” I replied. “Just as eating one fruit might satisfy hunger better than another without being stronger, its advantage lies in its being different.”

But I digress… . Patients now have two quandaries when obtaining prescribed drugs. The first is the limitation of allowed drugs on their prescriptions plan. Not infrequently an excluded drug may have quickened recovery from a disease process with fewer side effects. This is the essence of the battle between Gilead and Abbvie as Gilead has the more efficacious drug with the least side effects for treating hepatitis C but Abbvie has a cost advantage. The second is the co-pay which is part of patient prescription drug plans. Patients are confused between what their co-pay mandates them to pay and the cost of the drug. In the Medicare population this frequently results in patients being told by pharmacists what the list price of the drug is as a preface to what they owe. The natural response by the patient is anger that the drug is expensive even though the patient cost is much lower than the list price.

I judge that it is not unlikely that insurers have contracts with pharmacies and/or with pharmaceutical companies to limit the cost of specified drugs so that communicating the list price of a drug is not relevant to the prescription in question. In this era of confrontation and misinformation each participant: the patient, the pharmacist, and the pharmaceutical company have an agenda which ultimately inflames public perception.

Two other variables alter the public’s ability to obtain cost-effective medication. The first is the sheer amount of paper-work necessary to complete a prescription for a slew of medications which are proven efficacious but which cost more than the majority of medications. The irony here is that the cost of the medicine may be a fraction of the cost of treating with an inferior set of medications. An excellent example is hepatitis C which can be treated at a cost of 85,000.00 vs cost of lifetime care of a patient at more than 500,000.00. Similar examples can be given for psoriasis and arthritis. The second variable is the obfuscation of cost of medications by pharmaceutical companies that provide coupons for patients which limit the patient’s co-pay. The coupons fail to state that the purpose is to increase sales at the expense of insurers who must pay the balance owed on a more expensive drug.

In summary there are no heroes in these games, only selfish participants. Patients, doctors, insurers, pharmacies, and pharmaceutical companies each have their own self-interests. Yet it is axiomatic that from overcoming obstacles comes innovation. This is no less true in the medical therapeutic field. Next blog: inexpensive innovations in medical therapy, or, Back to the Future

Why Your Medicine Costs So Much: Thank you Senators Kennedy et. al.

The late Senator Ted Kennedy, like most senators a self-aggrandizing hypocrite, was also a savvy politician and ultimately an effective legislator. In an egregious moment which shall stand in the halls of my memory, so long as it may continue to function, Senator Kennedy passed legislation which in retrospect was a tawdry attempt to assuage his more left-leaning followers, but which resulted in one of the most significant attacks on patient care in the history of my life. To quote Mark Twain, “To promise not to do a thing is the surest way in the world to make a body want to go and do that very thing”. And the thing the Senator promised not to do was to promote an unhealthy alliance between young doctors-in-training and pharmaceutical companies.

Prompted by a friend who called to complain that he had just moved to a new city and had developed a consuming case of jock-itch, I was moved to consider what had become of physician concern for patient welfare. Not knowing physicians in his new locale my friend searched the internet for the name of a dermatologist and was promptly given an appointment. Performing a cursory visual exam, sans any testing, the doctor concluded that my friend had a fungus infection of the groin. The dermatologist, having recently left the cocoon of a university training program, prescribed what-to-her was an appropriate and modern topical cream therapy. When the patient arrived at the pharmacy he was told the cost of the cream was 300.00. Incredulous, he asked if his medical insurance would cover its cost and was told the insurance had already covered 200.00 and the rest was his responsibility! The total cost of a tube of this miracle cream was 500.00. I responded to his lament by recommending an over-the-counter anti-fungal cream which cost 12.00!

Getting back to Senator Kennedy, the Senator deemed that pharmaceutical company gifts to medical students was influencing their neophyte prescribing patterns and worse, might create a relationship of indebtedness which would corrupt the psyche of these young doctors forever. To wit, Eli Lilly Company could no longer distribute doctor bags to medical students completing their second year of medical school and other companies could no longer sponsor trips to major medical meetings for senior residents. (I was in the last class of medical students to receive said physician bag and with no sense of disingenuousness have a great affection for the bag and its history of having accompanied me over more than 4 decades of clinical practice. I rarely prescribe Eli Lilly products because most of their products do not fall into my therapeutic armamentarium.)

Henceforth, the pharmaceutical industry would have to find other ways to communicate with medical students and physicians. Furthermore, as government funding of research would wither, the pharmaceutical industry was asked to bear the burden of drug research with the caveat that monetary gains from such research would be considered ill begotten. As these congressmen pandered to the populist cause, they failed to see the unintended consequences of knowledge deficits and loss of ingenuity that would characterize the next 3 generations of physicians. With little information in basic science and in pharmacology physicians increasingly adhered to the principal that newer is better. The pharmaceutical industry reverted to a more passive –aggressive posture of reformulating existing drugs and packaging them as ever more expensive products. The liability risks of new drug formulations became simply too expensive to justify new drug research. (This resulted in creating what we now term the biotechnology industry.) Economic and bureaucratic pressures on physicians and academia alike produced ever more expediencies in physician education. Ask any credible drug rep and they will tell you that only rarely do physicians want information regarding pharmacology and rely on drug advertising to influence their prescribing of new products. Hence young physicians are preoccupied with new drug formulations which are reformulations of older drugs sold at ever increasing cost.

Beware Senator Kennedy. You knew not what you asked for and we are paying for it in spades.

Next blog will discuss the two tiered economic system of medicinal drug distribution based on how much premium the consumer can pay for medical insurance.