keenoctopus's Open Salon Blog

Why I Want To Go Into H.I.M.

Sat, 11 Jul 2009 21:07:34 -0400

Note: Sorry, folks, the above acronym is not meant to be read as anything other than Health Information Management. This post isn't about sex or Jesus - no physical or spiritual merging involved. But I got your attention, didn't I?

So my friend Rosario told me a story last night over the phone that made my blood boil. She is a South American doctoral student at a U.S. university, and she just had a run-in with our health care system which is, sadly, not the first she's had, but probably the worst thus far.

A few weeks ago she noticed discharge coming from one of her breasts, and, like any woman would, she went to the nearest health care provider (in her case, the campus health center) to be examined. I think the provider she saw must have been a nurse practitioner or a physician's assistant, and while these are generally highly trained individuals who often perform the bulk of day-to-day consultations in larger medical practices, those employed by campus clinics tend to be less than stellar, at least in my own and many of my friends' experience. I'm not sure how much of Rosario's negative experience was attributable to this particular NP/PA's skill deficiency, but what will become clear as I proceed is the deficiency of communication among the different "points of service" Rosario had to navigate.

The NP/PA (hitherto NP b/c I'm tired of typing NP/PA) dutifully examined her patient, which was a good start, but her next move signaled the beginning of a real runaround for Rosario.

"I'll just send this to the lab for testing to rule out cancer..."

This before she even suggested possible causes besides cancer, of which there are many. She cut right to the dreaded C word and, not surprisingly, took Rosario by surprise. The thought had occurred to Rosario, but for it to be practically the first thing out of the NP's mouth was very unsettling.

And that was basically the end of the visit. No further explanation was forthcoming. It was in and out and on to the next patient.

So the sample was sent to a lab, and Rosario waited the next week and a half for the results, worriedly wondering about them when she wasn't busy preparing for the summer classes she was teaching at the time.

Thankfully, the results were negative for cancer, but of course the test was not covered under Rosario's meager student health insurance. (I should tell you that money is very tight for Rosario and has been since she started school in the U.S. as an undergrad - due to poor currency exchange rates between here and her home country, any financial help her parents might send her wouldn't be much help at all, so she is entirely self-sufficient, and assistantship stipends keep their recipients below poverty level. I've never known anyone more frugal than Rosario, but it's because she has no choice!)

The NP had requested that Rosario come to a follow-up appointment, and while one would assume that this would've been a good time to go over possible alternative causes of the discharge, Rosario was instead prescribed a trip to the local hospital, this time for a mammogram. Apparently the NP wanted to be extra sure that there was no cancer before she even suggested any of the other possible - and much more likely - roots of the problem. Again, in and out and on to the next patient. It was as though the NP wanted to put off actually administering any treatment herself until she'd exhausted all means of delegating it to someone else, with no regard for the expense it was imposing on Rosario.

So, off to the hospital, no easy feat since Rosario has no car or driver's license and the hospital is far from campus. She managed to figure out which linked bus routes would get her closest and spent most of her day going to and from, meeting only briefly with the referral physician, who told her he had no idea why the NP had prescribed a mammogram - Rosario is only 27, too young for a mammogram to be an effective enough method of diagnosis. His own explanation for the discharge was much simpler: It's a common problem among women, and while sometimes it can indicate something serious, since Rosario's appeared to have subsided, it was nothing to worry about.

But her bill for the test and referral visit - over $400 - is something for her to worry about.

Yes, it's looking more and more like the NP's lack of competence was a big part of the problem...

And yet, it's not the worst part, or at least that's what proponents of greatly expanded health information technology and use of electronic medical records (HIT and EMRs, respectively) have been arguing for some time. True, the crux of medical care is the "points of service" themselves - the hospitals, doctors, specialists, pharmacists, and the myriad technicians associated with all of the above - and the whole system can't function if these moving parts don't work as they're supposed to. But if there is insufficient communication between the provider and the patient, or between two providers, or both (as in Rosario's case), then poor care is made worse, and the efficiency of decent care is impaired.

Had the university clinic been connected electronically with the hospital as part of a computer-based health information management (HIM) system, then the NP's request for a mammogram (which she'd have posted within Rosario's EMR) could have been questioned remotely by one of the doctor's nurses on the system-wide data platform, the doctor could have responded that the procedure was unnecessary, this advisement would have appeared within the NP's daily worklist, and the NP could decide on another mode of treatment - sparing Rosario, at the very least, the cost and inconvenience of the referral visit.

As for the bulk of this whole ordeal's expense, even the lab test may have been avoided if this hypothetical system of electonic records had an added level of sophistication - that is, an algorithmic component to ensure that the NP followed a set diagnostic procedure before she ordered anything as costly as a lab test. HMOs and large service providers such as hospitals normally require that their practioners adhere to rigorous checklists to eliminate any diagnoses that might be readily treated for the least amount of money before more expensive diagnostic methods are tried. Following such checklists can be tedious and time-consuming, and practitioners are usually under pressure to do everything as quickly and efficiently as possible, but as most Americans know, keeping health care costs down is more important than ever. Preventing unnecessary medical procedures will go a long way towards both keeping costs down and improving quality of care. Overtreating is, after all, no better for your health than undertreating, and is oftentimes worse (I have enough stories about friends' and relatives' overtreatment to fill another lengthy blog altogether).

To return to the NP in question, the existence of an electronic procedural component within the (still hypothetical) health info management software could have ensured efficiency, especially if there were an administrative mandate that she actually adhere to the procedure; the mandate could even be enforced by the software itself, preventing her progress down the list if she tried to skip steps.

There are plenty of health care providers, especially small independent clinics, who resist the idea of this sort of digital Big Brother watching everything they do and dictating how they treat patients. But there are also large hospitals that can't imagine getting along without their health info management software and EMR systems. I work for one such hospital. Our "e-chart" platform is far from perfect - nurses sometimes click "complete" on worklist items that aren't yet completed, messages get mis-routed, and doctors sometimes forget to check their worklists regularly. Trust me, when a patient comes in expecting prescriptions that we haven't received because the nurse prematurely "completed" the request, or a computer glitch sent the rx to another pharmacy, we techs reminisce about the days when everything was done over the phone, person-to-person, with no potentially glitchy system to throw things off. But then we remember that with the workload we currently have, there would be no way we could get half as much done if we were always on the phone, something that is true for every lab, clinic, and doctor's office affiliated with the hospital. Besides, doctors and nurses are notoriously difficult to get on the phone. Ack.

...I apologize if this got boring long ago. It's harder to argue a point from the technical side of things than the anecdotal, or it's at least less interesting. It can also be difficult to convince health care consumers of the advantages of HIM/HIT by presenting them as advantages for care providers - HMOs, big hospitals, pharmacies, "cutting costs" ... most people have more negative impressions of these than positive. These entities after all represent the money side of things, and it's not nice to think of one's good health as contingent upon how much one can spend. The good news, though, is something I hope I've helped to illustrate by telling Rosario's story and relating a bit of what I've learned about HIM/HIT through experience and through research in my spare time: Good health is not contingent strictly upon how much one can spend. Good health is contingent upon good service providers and upon the synergy of patients' providers with each other, with the patients, and with the massive amount of information constantly zipping and changing and growing.

And, oh yeah - my other point to all this was supposed to be that I've been inspired to get a master's in HIM, and how nice it is to have a possible career in mind after years of drift, especially a career where there's so much potential to improve the lives of other people. Yay! (she says with some restraint, since expansion of HIT is no small feat, and it will be rough going for a while)...

End note: I didn't say much about how communication between patient and provider could be improved - Rosario surely would have been spared a lot of trouble if, for one, her NP were more forthright and attentive, and two, Rosario were more aware of resources available to her (many of them online) that would help her validate both her NP's decisions and the potential costs of procedures ahead of time. But I plan to try and address this stuff in a future post...

Walter is 13!

Tue, 7 Jul 2009 21:07:26 -0400

The giantest cat my family has ever had just turned 13 on July 4! Happy belated birthday, America, AND Walter!

No serious posts are forthcoming at the moment, nor will they be for the foreseeable future - or at least not until I've gotten a good night's sleep and can think critically - hence this loving fluff-headed ode to a favorite kitty. I will proceed with a list of thirteen charming Walter Moments:

1) When my parents and sisters first went to see Walter (who was not yet Walter) and his siblings, the little furhead won over all with the matched black paintbrush-stroke-ish markings on his hind hocks. As he cavorted in clumsy kitten play, these little British-style single quote marks kept his fluffy tail correctly attributed to his bottom.

2) On the way to his new home, my mom decided to name him for her brother Buddy, who has always hated his given name (hence "Buddy"). And though it crossed no one's mind at the time, "Walter" is a stately name in a grand tradition of stately cat names: Preceding him in our household were Arthur, Duncan, Oscar, Benjamin, Franklin, Gandalf, and Bilbo.

3) On the same trip home, as he traveled ever further away from his mother, Walter amazed everyone in the car with his absurdly effeminate chirps of distress - strange for so robust and macho a kitten!

4) Upon my first Walter encounter while home for Thanksgiving break, I was less than impressed. He seemed very blah. Very big, but very blah. And his eyeliner somehow knocked a few points off my impression of his IQ. Plus he snorted instead of purring.

5) Walter grew to 22 pounds of muscle in short order and became very testosteroney. My dad refused to let my mom get him neutered, we think because that would have left Dad the only intact male in the house. But then Walter exploded through a basement window to get at a stray orange tom in the front yard, badly slicing his nose in the process, and my mom won the argument that by this point had been going on for a year. Walter went to the vet for his nose - and for The Snip.

6) My sister went to collect Walter after said Snip, and the vet tech offered to give her the surgery-leavings in a jar - the vet had judged them the biggest cat testicles she had ever had the pleasure of removing. (Imagine all the unwanted kittens spared a lean life on the streets!)

7) When Walter was brought out to my sister in the waiting room - held as one would hold a two-year-old child since he was just as big - he turned and reached for her like a toddler who had feared himself abandoned forever.

8) Following his surgery, Walter became mellower and more loving. His snorts turned into snorty purrs that could be heard across the room over the television. And he settled into life post-tomcat as the best electric blanket ever.

9) Enter kitten Andrew. Walter would let this tiny new upstart teethe viciously on his ears and tail until enough was enough, at which point Walter would sit on Andrew's head. The behemoth's purrs of satisfaction all but drowned out his tormentor's squalls of terrified indignation until a passer-by came to the rescue.

10) We invented the Kleenex Bib especially for Walter, and we use it to this day in times of need. It consists of an unfolded Kleenex twisted at two corners to two more Kleenexes, rolled, that serve as bib closures. The bib, when properly fitted, rests under Walter's chin to absorb the excess drool elicited by cuddling, thereby saving shirts and jeans from unslightly wet patches.

11) Walter loves to lick hair and moustaches. He has scared several visitors - including my 80-year-old grandmother - half to death by sneaking up behind them on couch-backs and licking their heads. He also enjoys climbing up next to my dad when he's asleep on the sofa and licking his moustache. My mom says this is because my dad is a messy eater.

12) Walter must sit in your lap. Even if there is one or even two cats already in it. This is another situation which Walter deems most easily solved by sitting on other cats. Also, kneeling on the ground while giving fresh water is read by Walter as an invitation to sit in your lap - he does not care that kneeling does not create a true lap and that by climbing on you in that position he places undue strain on your quadruceps and ankles. He does not even care that it is uncomfortable for him too. He just wants to be near you.

13) Now that he is old, Walter does not clean himself as well as he used to and gets bad mats on his rear end and tummy. He looks like a bedraggled old man. But this means that from time to time he gets a thorough dematting at the practiced hands of my mom - see picture below. Note his monstrous paws curled mid-knead and his eyes half-closed in bliss. Dematting is his favorite thing in the world. Next to laps. And moustaches.

Here's to you, Walter! We love you! <3

Writing Stories, Writing Life

Sun, 28 Jun 2009 15:06:04 -0400

Since I want to post something but am too lazy today to write new stuff, here's a paper - a "literacy narrative" - that I wrote for one of my graduate seminars two years ago. It turned out to be one of my better pieces that semester, and I didn't even have to dissect a 600-page novel! Well, maybe that's why it was better. Also I was writing what I knew, which is the way to go, so they say.

Enjoy!

**************

I have a confession to make.

When I was five years old, I plagiarized my first book. It was entitled The Caterpillar Who Turned Into a Butterfly, and I even copied the illustrations. This would not have been quite so scandalous if I hadn’t presented the finished manuscript to my kindergarten teacher and passed it off as my own work. I was a bright kid who could already read and write before starting school, so she believed me. To this day, she still does not know my dark secret—please don’t tell her.

After Caterpillar, there were others, a veritable slew of storybooks to which I affixed my name, crediting myself as both writer and illustrator (I in fact traced the drawings more often than not). I knew that someone else had written these books, but I hadn’t yet grasped the concept of the “creative process” and thought that aping other writers and artists—well, the end result was the same, wasn’t it? If anything, I bet I worked harder.

Eventually—thank God—I figured out what it meant to be creative, more or less, and I began coming up with my own stuff, thereby nipping in the bud the life of crime that surely awaited me had I not cleaned up my act. Admittedly, my first series of stories featured a character stolen from a children’s literary journal: a girl slightly older than myself (I was in second grade at the time) had written about the birth of a two-headed calf on her family’s farm, and I couldn’t ignore the storm of dramatic plotlines that began building in my mind as I read about this freakishly beguiling character—I firmly believed that the wee bovine gem deserved better than the banal narrative about double bottle-feedings to which the farm girl had confined it. I had to rescue it—rescue her, rather; her name was Esmeralda.

So I did. I renamed her Estimania (whole-cloth copying was no longer my M.O., after all; yet a rose by any other name, to my mind, was fair game) and began sending her on exciting adventures around the farmyard and beyond. And of course, in her new fictive realm, Estimania could talk. Out of both mouths, naturally.

But why stop with a talking two-headed calf? My storytelling flair, kindled though it may have been by illicit sparks, was rapidly developing as I churned out story after page-long story—no one character could keep up. I moved on to longer stories with bigger casts and more complicated plots. Outside of school, when I wasn’t reading, I was writing. I could not get through a novel without writing something of my own. Books about talking animals, such as Charlotte’s Web and The Wind in the Willows, inspired me to continue doing what I’d begun with Estimania. For some reason, it was so much easier for me to examine human hopes and foibles through the eyes of personified critters, and I stuck with what worked all through grade school.

It certainly did seem to work: I won my age group’s Young Author’s Contest three years running, first in third grade with Claws’n’Clues (a murder mystery set within a humanoid wolf clan), then in fourth grade with King (a fictionalized biography of my dad’s beloved childhood dog), and finally in fifth grade with Shyrak, the Hunted (a more “realistic” narrative account of a grizzly bear’s life-and-death struggles in the wild). Then, the contest judges asked me, admittedly in as nice a way as possible, to stop entering my stories. At first I was crushed—why punish me for throwing my heart and soul into my craft? I won simply because I absolutely loved what I was doing!—but was quickly pacified when the judges offered me the position of “junior” judge for the following year.

But the junior-judgeship was not to be mine; one of my classmates (a boy whose mom happened to be one of the adult judges) got the post instead. However, I was too distracted by my tween troubles to take notice. It had occurred to me, almost overnight, that the world was not quite as sunshiney and me-centered as I’d so long believed—amazing, yes, that my Freudian oral phase managed to last all those years, but when the end hit, it hit hard.

I pitched face-first into my adolescence. Acne, gawkiness, buckteeth, braces … it was not pretty. My writing career was now a foregone conclusion; it was all I could do simply to stay afloat in the treacherous ocean that was middle school. I played sports, I followed the fashion trends of Seventeen magazine, I listened to Green Day and Weezer and the Cranberries, and when all else failed, I made myself invisible. Actually, invisibility was my Plan A, and the rest was back-up. All in all my strategy was a success; I was surely one of the most unremarkable kids in school, at least in terms of star power.

Academically, though, I was still up there. And this turned out to be my saving grace (or so I thought at the time)—I was picked by the Illinois Math and Science Academy in Aurora to tour their school on a designated Junior Scholar day during my seventh and eighth grade years, and after the first visit, I knew this place was where I belonged. Acceptance to IMSA became my mission for the next three years. I even entered the Young Author’s Contest again in eighth grade so I could put it on my application, though when I won this time, it was over far fewer submissions—junior high kids are, after all, too cool to spend their free time writing stories. (This time around, in case you’re curious, I tried my hand at science fiction; the protagonist was an emotionless extraterrestrial who suddenly found himself able to “feel” things after sucking the life force from a human being. Hey, it beat the honorable-mention story about Mormonism.)

And I got into IMSA, and I moved up to Aurora, and I was happy … But then things changed, and I didn’t write anything worth reading for a while.

***

When I did write again—really sat down and threw my heart into it like in the old days—I was a junior in college, a recent convert from bio-major to rhetoric-major. The story was something I’d never before attempted, a first-person, present-tense “account” of one fifteen-year-old girl’s ten-day experience in an adolescent mental-health unit.

Given in her own voice, the narrative was by turns exhilarating and terrifying, a patchwork of vibrant scenes filled with colors and spectacular people who were not really there. Lurking at the edges were shadowy figures visible only to the reader—despair, shame, madness. Doctors, orderlies, patients, and parents were all shafts of reality cast down into a feverish world so that readers would not become hopelessly lost, though for the questing hero—as she saw herself—this world was more real than that from which she had so suddenly departed.

And as she was forcibly brought back to earth with powerful drugs, the readers sank with her into an ever-cloudier delirium, though their descent was mercifully staggered with brief doctors’ notes about the hero’s “real” condition. The readers knew she was sick; she knew she was not, right up to the point when she could no longer stay awake for more than two hours at a time.

The narrative ended with her discharge from the hospital; the readers left the hero in a heap, a vapid shell of her former ecstatic self. A tragic ending. But the story continued for many years.

By the time I got this down on paper at age 21, I had come a long way. I’d even begun to think of reasons why it all had happened to me. Surely, when someone “breaks down”—even for a little while—it is so she can build herself again. But whatever the circumstantial catalysts of my illness—being away from home, living full-time with peers, learning mind-boggling things from the most innovative teachers I’d ever had, eating too little, sleeping too little, all of the above—there was no doubt I was ill, and the road back from my own personal hell would prove grueling, to say the least.

Sure, I had a clean slate when I arrived home from the hospital; in fact, the drugs had all but taken me back to square one when it came to academic capacity. But the mouth-drying, muscle-stiffening side-effects ensured that my days at school—mere half-days at first—were agony. Two months after my return to school in my hometown (a return to IMSA was, of course, out of the question), I could still barely write a sentence, partly due to my impaired manual dexterity and partly because I found it so difficult to corral my own murky thoughts, both thanks to my medications. And as far as I was able to comprehend what had befallen me, I was heartbroken. If I couldn’t write, where was I? Who was I, now?

I had no choice but to muddle through, with or without any solid sense of self. The drugs kept changing over the two years following my hospital stay, down to no drugs at one point—but that was only until a second “manic” episode set in and the doctors could diagnose me as having bipolar disorder. From then on, I was being treated for a specific illness rather than for my symptoms, and the going slowly began to get easier. But I wasn’t writing anymore, certainly not with the passion I’d once taken for granted. I was afraid to find out just how much I had lost.

Until, that is, I succumbed to my university’s evil plan to “weed out” those biology majors who just didn’t have what it took to pursue a career in the life sciences—my half-hearted hope of becoming a veterinarian was, I must admit, not difficult to snuff with “C-“ after “C-“ in chemistry and calculus. University life had not, oddly enough, made any real ripples in my re-forged mental stability (it probably didn’t hurt that I stayed in my room glued to my TV when I wasn’t studying) but my facts-and-figures classes were kicking the tar out of me. So, I decided to face down my crisis of self-confidence and give writing another try.

It was like slipping back into a pair of favorite woolen socks that I’d thought were long ago devoured by the washing machine. I still had it. I could still fashion characters and create little worlds, I could still tell a story. Yet, it felt different. I found a lot more of myself leaking into the people on the page (yes, people—I’d graduated from animals and aliens) and the problems were more palpable, more…real. My creative writings no longer needed the element of fantasy—the real world was bizarre, thrilling, and cruel enough as it was. Since I’d been ill, I’d noticed the world around me as though for the first time. Everything had been inverted and violently shaken—my plans for success had been dashed—I had no choice but to sit back and simply watch the pieces settle. Flat-out failure had given me a new outlook.

It also prepared me for future trials. Such as the peer review workshop of my memoir Ten Days. The class had read it over the previous week in preparation, and when I arrived at the classroom, I was met with a silence that was nearly unbearable. But I was prepared—I’d known when I sat down to record my hospital experience that it was going to be tough for me to write and awkward for my classmates to workshop. I wasn’t going to let that stop me from telling the most important story I’d ever told. And I was ready for the questions that would come—ready, that is, to address these questions; even I did not know how to answer all the hows and certainly not the whys. But I could say that yes, this did happen to me, and I’m a better person for it. Not to mention a better writer.

Pharmacists and Techs: Believe It Or Not, We're On Your Side

Sat, 27 Jun 2009 20:06:52 -0400

On Wednesday, economist/domestic policy expert and Washington Post columnist Ezra Klein sprang a big one on readers: The health insurance industry is hell-bent on making money, first and last.

Michael Moore broadcast this fact in Sicko two years ago, but hey, it's a new presidential administration, a new media angle. Health care reform is now all the rage. Big Insurance and its sister Big Pharma have been belatedly identified as the bad guys, and not just by raging liberals.

Not that they were the only ones to agree with this truth when the film first came out - I remember seniors coming to the pharmacy where I used to work, gaping at their drug costs, finding out they were in the doughnut hole (better understood as the drug cost "coverage gap" in which the patient is responsible for 100% of the cost of their medicine until the "catastrophic" level - typically $2000-3000 - is reached), and sinking into a confused, anxious haze while I or the pharmacist did our best to explain this surprise loophole. A few times I let slip the tip that Sicko was playing down the street at the Showplace 8, gave them a brief overview of the film's content, and was not surprised when they asked about show times. I don't know why I felt the need to be covert when I mentioned the movie to these patients - I would lower my voice, make sure the pharmacist/other techs weren't watching or listening, etc. - it must have been my instinct as someone on the far side of the health industry "counter," as it were.

Only later would I realize that most pharmacists are just as bitter about the Medicare Part D boondoggle - and for-profit insurance in general - as are so many patients. It comes of being at the person-to-person level of care, on the front lines miles away from administrative/legislative HQ, I suppose. One of the first things people see fit to tell me when I say I'm a pharmacy tech is that they've had some run-in or other with a rude pharmacist who "refused to give me my pills," and this does happen quite often, and there are a lot of cranky pharmacists out there (the reasons for which could fill another whole blog entirely - let me just say I would never want their job!) - but almost always the "refusal" is not on the pharmacist's order, but on that of the patient's insurance provider. Some grouchy pharmacists, it's true, have built up an abhorrence of the public over the years, a thick skin and preemptively temperamental tone after passing along this unpleasant news too many times to count. But when you get down to it, it isn't their fault. The insurance companies are covering their butts (i.e., minimizing "medical losses," as noted by Moore and Ezra Klein) by adhering to rigorous days' supply requirements, sometimes dubious drug formularies, "step-therapies," limits on retail pharmacy rx fills, etc., etc.

A run-down of the claim-rejects in the above partial list:

Days' supply: Most prescription insurances will cover only a 30- or 90-days' supply of medications, a regulation which many of you have no doubt encountered when you've made a pharmacy stop expecting to have your rx ready and waiting. This is annoying, yes, especially if you're about to leave the country for a month. But it's the most basic way to control costs, both the insurance providers' and the pharmacy's. An added plus is the prevention of medicine stockpiling, important for drug abusers and the doctors they harass for endless refills. It's also something that would definitely be included in any government plan, sorry to say, especially one that hopes to be as cost-conscious as Obama's.

Drug formularies: This regulation can often seem less reasonable, and oftentimes it really is. It's also a point at which Big Pharma and Big Insurance are usually at vicious odds. (Contrary to popular belief, despite their shared fiduciary interest in profiting off sick people, the industries are engaged in an epic battle: Pharma wants to sell lots of drugs, Insurance wants to pay as little as possible for them. In this situation, pharmacies and doctors are the beleaguered referees, more so the pharmacies since doctors aren't always up to speed on their patients' insurance limitations. Which can be a huge pain in the ass for us pharm folk.) Formularies are lists of drugs that insurance providers agree to cover, in whole (almost never) or in part (to widely varying degrees). When your doctor prescribes a drug that is not on your insurance's formulary (lots of new drugs fall into this category), they won't pay, or they'll contribute a miniscule amount that translates to "Bad patient! Tell your doctor to prescribe something cheaper!" The latter happens most often when a brand has become available in generic form. Insurance companies are always on top of the latest patent expirations. Formularies will exist under a government plan, but it's hoped that the plan will pay more attention to drug efficacy than cost when determining which drugs to include.

Step therapies: Has your doctor ever prescribed a new drug that your insurance won't cover because they want you to try something(s) else first? Very common with antidepressants, this obstacle to prescribed treatment may postpone your doctor's and your desired results. In this case, your insurance wants to pay for a cheaper drug before they'll give in and dole it out for what your MD deemed best for you in the first place. Sometimes the substituted drug works well enough and money is saved, but it can be galling to tough out the inferior treatment when it doesn't. Probably this won't disappear with a government plan, but again, hopefully efficacy will have greater weight. After all, despite heavy industry marketing of certain brand-name drugs (see Seroquel, Seroquel Part II), they aren't always any better or have fewer side-effects than older ones.

Limits on retail pharmacy fills: Some insurance companies have deals with pharmaceutical distributors that require patients to "go to mail-order" after a set number of rx fills at a retail pharmacy, usually 2 or 3. In my experience this has been most common among seniors' Medicare Advantage plans and some employer-provided insurances, to sometimes detrimental effect - snail mail is so reliable, after all. I've encountered many instances of patients being forced to pay cash for a guesstimated number of pills to tide them over until their covered prescription would (hopefully) arrive in the mail.

Again, this is just a partial list. Probably on Monday when I go back to work, we pharmacy techs and pharmacists will run into common claim-rejects that I couldn't call to mind for this post, and I'll think, Dammit, that was a good one. I didn't even touch the dreaded Prior Authorization!

So, yeah. We in the pharmacy business may sometimes be cranky, but it's just because we care! Or something. Seriously, though, insurance is just about as confounding for us as it is for you. Not only are we negotiators, but we have our own health insurance, too. We just get paid to go to bat for you guys as well. Or at least try.

"What Pharma Giveth, Obama Taketh Away" - Not so fast!

Wed, 24 Jun 2009 21:06:45 -0400

In his Monday blog, "Drug Wonk" Dr Robert Goldberg comments on the news that President Obama and Congress have gotten Big Pharma to agree to pay $80 million towards covering some of lower- and middle-income seniors' brand name drug costs while they're in the "donut hole" (the infamous bait-and-switch scheme written into the Medicare Part D law by lawmakers and the relevant industries in 2003).

Here's Goldberg's rather left-handed praise:

"So drug and biotech companies are finally being permitted what they wanted to do all along but were banned from doing -- giving seniors a discount to give them a seamless drug benefit. That makes sense since the decision about what drug to take should be what works, not the price or cost. At least that is what the evidence says. And making that decision on clinical evidence leads to value based benefit designs which focus on overall health outcomes."

I call this left-handed because Goldberg credits drug companies with the desire to give seniors a "seamless drug benefit" and thus implicitly criticizes lawmakers for not having "permitted" them to do this
before now. As if the drug industry actually cares about all that value-based benefit stuff - the fact of the matter is that the industry, being an industry, is driven by its bottom line. Of course drug prices matter to them, but this has little to do with whether or not brand-name drugs work better than cheaper generics. If the industry can subsidize part of seniors' brand-name drug costs, that's that many more prescriptions being written for those medicines on which the drug companies still have active patents. It does better than balance out for the industry - we can rest assured that pharm company accountants are being paid a pretty penny to make sure of this before offering to "help" seniors. And an industry focus on "overall health outcomes"? Needless to say, it is to laugh.

Fortunately, that's where the Obama Administration and a bipartisan coalition of lawmakers are stepping in. Peter Orszag, Obama's Directer of the Office of Management and Budget, has fingered exorbitantly wasteful health spending as our country's biggest financial drain, and has outlined real "value based benefit designs" to cut spending while improving quality of care ("real" as in driven by concern for the public welfare rather than profits, as in the cases of Big Pharma and Insurance). Here's Orszag's May 15 article in the Wall Street Journal.

Unfortunately, Goldberg goes on to mislead readers by generalizing the Administration's specific cost-cutting proposals. He rightfully notes that Medicare payments to hospitals would be reduced, but he neglects to mention that these reductions will be directed at providers who provide inadequate care that results in high rates of hospital readmission. Most people would agree that it makes no sense for the government to subsidize poor health care.

And it makes no sense for the government to subsidize private companies that work unseemly profit margins into their government-contracted services. Which is precisely what has been happening with Medicare Advantage, something else that Goldberg conveniently fails to mention when he wonders how the scheduled elimination of Advantage (in 2011) will affect those currently covered. Medicare Advantage is a network of plans offered by insurance companies to Medicare Part D beneficiaries (mainly seniors and the disabled) whose Part D plans don't sufficiently ease their drug spending. Of course, there would be no need for these supplementary Advantage plans if the Bush Administration had cared more about cost-effectiveness than the Pharm and Insurance industries in the first place. Sigh.

ANYway, cutting wasteful payments to Medicare Advantage plans, along with those to inefficient health care providers, makes sense. According to health care economist Maggie Mahar, the Advantage plans are hardly the saviors Goldberg makes them out to be: They demand government reimbursements that are 17% above what Medicare would spend on the same treatments if it were paying for them directly, without these profit-seeking middlemen. In addition, the particulars of Advantage plans are very confusing for ill seniors and are riddled with hidden disadvantages, a long list of which Mahar provides on her Health Beat blog.

So when Goldberg criticizes Obama for "pillaging the one part of Medicare that provides...a preventive approach to health care" (not sure where the heck he got the idea that Advantage represents a preventive approach), he's really criticizing the excision of ineffective money-sponges from health care reform. Big surprise, coming from a guy who works for the "astroturf tort 'reform' group for the big drug companies," the Center for Medicine in the Public Interest. (No joke, I just uncovered this tidbit seconds ago while locating links for this post.)

It just goes to show - there is always more to the story! Gotta love the Internets.