Evan Levine, M.D.

Healthcare - A behind the scenes look

Dr. Evan Levine

Dr. Evan Levine
March 17
Author of What Your Doctor Won't (or Can't) Tell You - Penguin Publishing. Fellow of American College of Cardiology and practicing cardiologist in Bronx and Westchester New York. Today Show Interview: http://www.youtube.com/watch?v=63cWvtGPonU Follow me on Twitter: https://twitter.com/vanlev


DECEMBER 12, 2010 3:02PM

Healthcare too expensive? Blame some of the patients.

Rate: 11 Flag


     There are many reasons why the cost of our healthcare is so high   but waste plain and simple remains the costliest of all. Many blame the professionals, but few blame the patients, and then only rarely.  A few weeks ago I came across two patients from opposite ends of the socioeconomic spectrum. One who possessed extraordinary wealth and education; the other with very little of either. They had one thing in common, however; they were both willing to exploit, no, cheat their healthcare plan, for their own different reasons, and in spite of any evidence-based science that it would benefit them.    

        While at a social gathering I met a forty-year-old gentleman who told me in passing that he was going to have a colonoscopy.  We were not well acquainted but he knew me by name and that I was a physician and so I guess he figured he could talk to me about it.  I learned he was quite wealthy and had been educated at a prestigious college.  He had no genetic risks for colon cancer and no symptoms, so I wondered aloud why he was going to get a colonoscopy at such a young age. The usual screening age for low risk individuals is 50.           

    He told me he and his friends, all of whom were making plans to do the same, figured it could do no harm to have one. He had already scheduled it already with a doctor he believes to be very qualified and who had already accepted his insurance.  I suppose he might have expected me to be impressed with his forward-looking, preventative approach, but he was not happy with my response.  "So you are going to have an unindicated procedure for which your doctor is going to have to commit insurance fraud because he’s going to have to put some fake reason why you needed it so he can get paid by the insurance company?"  That was the end of our conversation.  I’ll bet he thought I was quite an ass.  

    A few days later, on a Saturday afternoon, an elderly uneducated woman who has Medicaid paying for her prescription drugs called my answering service and told the operator it was an emergency and she needed to speak to a doctor. Her doctor had given her the wrong prescription, my text message said.This sort of mistake, though rare, can be quite serious, so I called her back within a few minutes, as I always do, and asked what the emergency was.  She told me my partner at the practice had written her a script for a “genetic” (she meant “generic”) version of Norvasc and she refused to take “genetic” drugs.           

   Like many of you, I spend about $15,000 a year for my health insurance. I have a large co-pay for brand drugs and a smaller one for generics. I take generic drugs, my wife takes generic drugs, and my kids are given generic drugs.   Generic drugs are good enough for a physician and his family who pays $15,000 a year out of pocket for his health plan but not good enough for a patient who pays nothing (Medicaid pays for her prescription drugs) for her care and doesn't even know the difference between “genetic” and “generic.”           

     When I told her that the two drugs were virtually identical and that her call was not an emergency, she became extremely upset with me. I reminded her that I was available for urgent calls only, and asked her not to abuse her privilege.  I mentioned to her that my entire family takes generic medications and I would not call the pharmacy to authorize a brand name for her medication.  She suggested she would leave our practice and find someone who would and I bet she just might. Leave and find a doctor willing to do whatever it takes to keep her as a patient, no matter what the cost to the health care system as a whole..

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I am sure this happens all too often. I am A OK with generic meds for my genetic ailments....Cheers!
I have occasionally heard people say that for certain meds, the generic doesn't work as well. I have rarely heard this. I am fine with generic, too.
And I plan on never having a colonoscopy! :)
On the rare occasions when I agree with my doctor that a prescription drug could help me, I ask for generic. I think many people don't understand what generic means. People don't buy store label foods for the same reason. Your patient may have been afraid of what she did not understand.
There's no data that shows that screening colonoscopy reduces anyone's chances of dying prematurely. I was astounded to learn that someone is willing to game the system for the "privilege" of being sodomized with a fiber-optic cable. But that's what you get in a society when drug companies and manufacturers of medical devices take our money and use it to saturate us with the message that we are all fragile, disease-ridden time bombs who must endlessly perform rituals like mammography and colonoscopy to keep the specter of death at bay.

Why are you prescribing norvasc? Wouldn't a gentle diuretic be safer and cheaper, and just as effective?
This so resonates with me, Evan. Thank you for expressing these thoughts in a clear voice. May all who receive health care be aware that fraud is not only a felony--it costs everyone, whether we're guilty of it or not. We ourselves may not be committing the crime but we all pay for it, in increased insurance payments or lack of available services. Rated. D
Patrick, my first choice is usually a gentile diuretic since it costs about four-cents a day and works better than most other drugs. But there are many patients that require other drugs or many drugs to control
Patrick, my first choice is usually a gentile diuretic since it costs about four-cents a day and works better than most other drugs. But there are many patients that require other drugs or many drugs to control
Yes, I suppose one can blame the patient in these cases. That said, they wouldn't get anything unless some doctor signed for it. As the old saying goes, the most expensive piece of medical equipment is the doctor's pen.

Personally, I can't imagine why anyone would want an unnecessary colonoscopy, or any other unnecessary procedure. There are risks to everything, not to mention that the whole procedure is damned unpleasant.
Let's not forget those who have insurance that pays for a yearly physical - and then refuse or forget to schedule a physical. In my opinion, anyone who habitually misses a yearly physical ought to have their medical coverage canceled. I suppose we could also add those individuals who do go for a physical and then completely disregard any advice given. Both behaviors are adding unnecessary costs to an already overtaxed system.
If you are willing to drink that nasty prep for the colonoscopy may I suggest that the doctor is checking the wrong end.
To Dr. Levine:

Thanks for the info.
To Dr. Levine:

I am glad to see you prescribe generic drugs for your patients. Leaving the issue of cost aside, if the patent hasn't expired thta means the drug probably hasn't been around long enough to make sure it has no serious long-term side effects.
To The Feral Conservative:

"...anyone who habitually misses a yearly physical ought to have their medical coverage canceled."

What kind of a "conservative" are you? I thought conservatives were supposed to be in favor of personal responsibility and free choice.

I am 49 years old and my modal annual expenditure on medical care is zero dollars. I don't go to a doctor unless I have a specific problem I want help with. Should it ever turn out to be something serious or chronic (so far it never has, knock wood), I'll make sure I know more about my problem than my doctors do. Otherwise, I leave well enough alone.

Going to a doctor when you aren't sick is -- literally -- looking for trouble.
Thanks for posting that. As a naturopath, my practice is entirely out of pocket pay for patients, and I don't want to opt in for some of the insurance contracts available to me. HSAs can reimburse for my services, but more importantly, most of what I do isn't very expensive and is not life saving (in the short term, long term it is). People get irate when medicare won't pay for acupuncture and sound nutritional advice, and I get irate that patients don't think they should have to pay for my services. I wonder sometimes who they think the "they" is who should be paying. Half or more of their health care issues are related to the choices they made elsewhere in life.
My average visit to a physician is maybe 3 per decade. All the Norwegians in my family of origin lived to a ripe old age (and none were on a regimen of pharmaceuticals). My neighbor across the street is 88 this year. She shared with me recently that she takes no meds too. Colon cancer doesn’t run in my family, so I haven’t felt a pressing need for a colonoscopy (even though I am over 50). I wonder if there might be a correlation between proactive self-care and education level?
@ Patrick: What kind of conservative am I? First, let me ask you why personal responsibility and free choice are conservative values to you - or anyone? What are the outcomes of your beliefs? I care not what the intentions are. A true conservative views results, not intentions.
Do you not change the oil in your car unless the push rods are knocking? Not going to the doctor for an annual is not practicing a conservative methods of health stewardship - it is quite liberal, and asking for trouble.
Your post seems to indicate that it's the doctors who are at fault here. Yes, the patients are being jerks. But the doctor, if he/she goes along with performing the unnecessary procedure or prescribing the name-brand drug, bears the ultimate responsibility.

I work with attorneys who, every day, tell people, "There is no legal remedy for you. We won't be filing a lawsuit." Why can't these doctors do the same thing?
A few comments:

Of course the responsibility also is with the physician but too many doctors would rather give the patient what the patients asks for instead of creating conflict or risking the loss of the patient.

Prevention remains the most important part of medicine and not expensive imaging studies or procedure. I bet that over half of all the imaging studies and stent procedures do nothing than make a few people very very wealthy.

Both the poor and uneducated and the rich and educated abuse the system. If you worked in the system you would see it quite clearly. Unfortunately the people that make the rules have no idea what is going on in healthcare
but too many doctors would rather give the patient what the patients asks for instead of creating conflict or risking the loss of the patient.

Then I would say that these doctors are not doing their job. Worse than that, they are the ones abusing the system in order to keep a patient.

I bet that over half of all the imaging studies and stent procedures do nothing than make a few people very very wealthy.

I assume that those few people are doctors. And you're complaining about patients because...?

Sorry, perhaps I'm being too argumentative, but there is very little you have said here that places more blame on the patient than on the doctor.

(I had several appointments with an orthopedic doctor last year after a dislocated elbow. He seemed to be genuinely offended when I asked him if I really needed to come and see him again. But I honestly felt he wasn't doing anything for me.)
Sorry, forgot to close italics in that last comment. I only meant to have your quotes italicized.
I was with you until the "doesn't know the difference bet. genetic and generic." That was kind of off topic. Meanwhile, what's your stance on mammograms? The Science Times says it's not necessary until 50. Should insurance pay for them? Just wondering... (I skipped my last one.)
I tried to make a point that some dolt who doesn't know the difference between genetic and generic nevertheless has the nerve to tell the doctor that they should only be given the brand name. I think that says an awful lot about the patient's chutzpah.

I am not an expert on the science of mammagrophy but I would go wiht what the experts and the studies say and not what the politicians and loud mouths opine.
After reading your blog post I could not be in more of a concordance. The rampant abuse I see of the medicaid system on a daily basis in the er has crossed over the border into the illegal realm eons ago. Upon discharge for viral syndrome (a most common complaint) patients with medicaid often demand a prescription for tylenol or motrin or both as well as a metrocard. This is simply on the basis that medicaid will pay for both. Sadly, these are the same patients who are talking on iphones (90+ dollars a month) and clutching prada ( fake or not) bags. Somehow money's are able to be allocated to those precious resources, but not to their own health care. The criminal abuse of the medicaid system in part is spurned by the providers. Namely the pediatric ER at Jacobi has a full stocked pharmacy the provides medications to patients upon discharge. Be it antibiotics, creams, or tylenol. I recently bought a small vial of nystatin for my daughters diaper rash. A nothing vial of cvs brand nystatin cost 10 dollars. We provide a vial 10 times the size of the one I bought for the fair market price of free.
Jacobi pediatric ER has one of the highest revisit rates of any facility I have ever worked in, and why not. If you as a patient have medicaid, you can call the ambulance, get seen in a reasonably fast period of time, get a good bag on discharge including a voucher for transportation home and pay nothing for the cost of all these luxuries, wouldn't you keep coming back?
One last example. I was working this past Friday night. EMS brings in a 19 year old shot once in the head. Patient was in extremis, necessitated intubation, however the trajectory of the bullet was such that instead of creating a most certainly fatal head wound, it rather took a path that caused a serious but survivable injury. Distraught family and friends began to pour into the ER causing a bit of an overcrowding situation shortly thereafter. As is the norm in these situations, we escort all visitors out during this tense situation for patient and staff safety. We have had incidents previously where the shooter has come to the ER to finish the job, and thus a crowded situation in the ER is a dangerous one. The family instead figured another way of getting to stay. Namely, registering as patients. They gave complaints such as back pain for 10 years, headache of 5 minutes, cough. Now, registration is not free. The mere act of being brought to the attention of the triage nurse costs 400 dollars. This is before any provider even see's you. Factoring this in mind, ten family members all with medicaid ( I checked) all registered in order to come in without any intention of ever being seen. This creates a drain on the triage nurses, paper waste and not to mention, 4000 dollars that will never be recouped.
I do not condone anyone who cheats the system but the last comment is quite true. I often pass the Medicaid office of the hospital i work at and I have noticed mothers wheeling their kids in a Maclaren Stroller and talking on an I Phone.

When I purchased our strollers I looked at the Maclaren model but found it a bit too expensive and not much better, and not safer, than a few other brands.

I wonder how the heck people living off public assistance , and on Medicaid, are able to afford such luxuries.
@ the Feral Conservative:

It depends on whether you want to see health as primarily a product manufactured by giant corporations, which they can vend to us or withhold from us at our displeasure, or whether you want to see it as a primarily a product of certain ways of living.

People are not cars. Health comes from exercising, eating sensibly, and refraining from smoking and excess drinking -- not from seeing a doctor when you aren't even sick.

In the book of Genesis, it says, "Our days in earth are threescore and ten, or fourscore if we are strong." In other words, we can infer that, at the time that was written, if you didn't die of accidents our violence or infectious disease, you could expect to live to be about eighty. Today, if you don't die of accidents or violence or infectious disease, you can expect to live to be about eighty. That hasn't changed. There's no convincing evidence that all this fussy, fearful concern with cancer screening, cholesterol levels, etc. has resulted in any signficant increase in life expectancy.

I don't need a doctor to tell me how I am. We have nervous sysems for that. I know how I feel. I feel great. I suppose it's theoretically posisble that I harbor th beginnings of some horrible metastatic cancer or other life-threatening condition which will kill me if I wait for symptoms to appear, BUT which if detected earlier at my checkup could be cured. If I get a checkup, what do you think the chances are of that happening, as opposed to the chances of having some medical intervention I don't really need foisted upon me? Have you any DATA that the ritual of the annual checkup produces a significant reduction in the likelihood of preamture death or some other hard clinical outcome, or just the self-serving pronouncements of a Medical-Industrial Complex which has an obvious vested interest in foisting on people as many interventions as they will stand for?

While I agree that too many doctors order too many tests there are also good reasons and evidence based reasons to get tested and examined.

A colonoscopy at the age of 50, and earlier if you have symptoms or a higher risk of disease, is one of these.

You should know if your cholesterol is high ,or if you have diabetes, or if there is evidence of high blood pressure or kidney disease.

Elizabeth Edwards, whose husband made millions on suing doctors, declined to get her mammogram done for years. Had she had it done as prescribed the cancer would have been found at an earlier stage.

Again, I agree with you that there is a serious criminal element in medicine looking to test patients on everything, and for no good reason, but you should consider simple tests to ensure you are OK.

While I agree that too many doctors order too many tests there are also good reasons and evidence based reasons to get tested and examined.

A colonoscopy at the age of 50, and earlier if you have symptoms or a higher risk of disease, is one of these.

You should know if your cholesterol is high ,or if you have diabetes, or if there is evidence of high blood pressure or kidney disease.

Elizabeth Edwards, whose husband made millions on suing doctors, declined to get her mammogram done for years. Had she had it done as prescribed the cancer would have been found at an earlier stage.

Again, I agree with you that there is a serious criminal element in medicine looking to test patients on everything, and for no good reason, but you should consider simple tests to ensure you are OK.
I am aware that there are interventions for elevated blood pressure or cholesterol levels which can produce small but measurable reductions in risk for the people who take them.
But there is no data which shows that they produce measurable reduction in risk for people who exercise strenuously every day. Nobody has ever done a study like that, and nobody ever will. Therefore, there is no reason to believe that they will do me any good, and therefore no reason for me to know my blood pressure or cholesterol levels.

I am wondering if you convey to your patients just how small the reduction in risk afforded by some of these interventions are. The dirty little secret of the pharmaceutical companies (well, one of their many dirty little secrets) is that many of these new “medicines” they are coming up with do NOTHING for most of the people who take them. Lowering blood pressure or cholesterol or blood sugar are not ends in themselves – they are worthwhile only insofar as they help people avoid death or some other hard clinical outcome (heart attack, stroke, etc.).

Take a drug like Pravachol. The West of Scotland Study showed that for every 100 patients who took this drug for five years, there were two fewer non-fatal heart attacks and one fewer death. If we are justified in lumping those two outcomes together (I’m not sure if we are) then we can say that Pravachol reduced these men’s chances of dying OR suffering a non-fatal heart attack by three percent. Now I’ll admit, grudgingly, that this is getting into the range worth taking seriously. But it doesn’t exactly strike me as something to scream about. Turning it around, it means that ninety-seven percent of the men who took this drug did not benefit at all. Why don’t they make this clear in the ads? “Pravachol may protect you from a heart attack or premature death – but it probably won’t.”

Other studies have reported even more meager reductions in risk. And some of the newer cholesterol-lowering drugs have been approved solely on the basis that they reduce cholesterol, without anyone even having to try to demonstrate that they produce any meaningful outcome for the patients who take them. Consider Zetia, a drug which reduces cholesterol but has unfortunate side effects for the people who take it, like killing them. Is that a good tradeoff?

And let’s not forget that the men in the West of Scotland Study were the men who were judged to be most at risk for a first heart attack. Every time they broaden the criteria for prescribing these drugs, the reduction in risk should go down even more, since the initial risk is smaller to begin with.

Anyway, who takes just one prescription drug anymore? The average senior citizen now takes five prescription drugs or supplements on a regular basis. Given that so many of these drugs were approved on the basis of such paltry effects, given the drug companies demonstrated willingness to suppress negative results, and there have been few studies on the effects of more than one drug at a time and no studies on the effects of taking more than three, I submit to you that we don’t know whether all this relentless drugging of our senior citizens is lengthening their lives, shortening them, or having no net effect at all.

We do know that between 1980 and 2003, pre capita spending on prescription drugs, adjusted for inflation, rose seventeen times. Not seventeen percent – seventeen TIMES as much. And during that period, life expectancy at 65 barely budged – and I’d be willing to bet that most of that increase – maybe all of it – is due to the fact that fewer people are smoking.

As for Elizabeth Edwards: of course screening mammography would have caught her cancer earlier. That’s not the same thing as saying she would have lived a day longer. A study published by the respected Cochrane Collaboration found that screening mammography was correlated with a one in two thousand reduction in the risk of dying of breast cancer, but there was no reduction in the only statistic that matters, the overall death rate. A Norwegian study published last September in the New England Journal of Medicine found that screening mammography was correlated with an even tinier reduction in the risk of dying of breast cancer – one in two thousand five hundred, which was found not to be statistically significant. The Norwegian study did not look at all cause mortality. What difference does it make if you die of breast cancer, or you die of something else at the exact same time? We all die of something, be it breast cancer or a heart attack or a stroke or getting run over by a bus on the way to the mammography clinic.

As for the jackass who is gaming the system to get a colonoscopy without any medical indications, I get the impression you are more angry about the fact that he is ignoring medical authority that the fact that there is no convincing evidence that screening colonoscopy reduces anyone’s chances of dying sooner. A study by Dr. Nancy Baxter and her colleagues published in Annals of Internal Medicine last year found that screening colonoscopy was correlated with a 69% reduction in risk of dying of colon cancer. Now, that sounds like an overwhelming reduction, but hold on here – 69% of what, exactly? One out of fifty deaths, or 2%, is due to colon cancer. 69% of 2 percent is one in seventy-two.

Is anyone living any longer? I emailed Dr. Baxter and she graciously replied that the study was not designed to answer that question. But given that the average age at diagnosis in that study was seventy-three, any reduction in the death rate produced by screening colonoscopy must be tiny. Let’s face it, at seventy-three you don’t have a lot of life left, whether you die of colon cancer or not.

Screening colonoscopy gives you a tiny, barely measurable reduction in the chance of having colon cancer listed as the cause of death on my death certificate. Where is the data that shows it will delay the DATE of my death?
Wow. I find it hard to blame the patient when there is a physician willing to do an unnecessary procedure. And the woman plainly does not understand, a very common problem. Lack of health literacy is as ubiquitous as lack of math knowledge - I'll bet neither of these folks could use trigonometry to solve for the side in a triangle either, but I wouldn't hold that against them.
As a health professional for 20 years in a large university hospital I find it ludicrous to suggest patients are in any way to blame for this mess we are in. A few patients may take advantage, but the staggering amount of malpractice that passes for following insurance guidelines and the amount of patients that actually incur injury or even die due to what we have to do to get paid is mountainous compared with the situation you cite. This post is angering. Blame the victims.
I just don't understand why it costs $2500/day to sleep on a hospital bed; why an ambulance can whack some poor bloke 650 bucks for a 3 mile ride to a doc; why a bill from a hospital includes a$15 dollar box of Kleenex.

Pretty simple: Because they can.
I certainly agree with what Flylooper writes and it is only going to get more expensive. Rita, I am sorry for your anger or for anyone else who could actually write something like you have. I suspect you have issues in your life but I ask you to read my other posts before coming to your conclusion. Patients are indeed a part of the problem ; just read the stories I just posted. Now calm down and try to debate without hostility.
I once had a patient's daughter tell me that her family had a genetic predisposition to reject generic drugs. She demanded that her mother receive only brand name drugs because Medicaid would take care of it. I told her that I did not know of any literature that could support this statement.