A recent article in the USA Today pointed out once more how the gap has widened between what people with insurance have to pay for their hospital stays versus people who go without insurance.  Since 1984, the uninsured pay nearly 3 times more than those who have health insurance.  This is disgusting.  The reason I say this is that it's the little man that gets hurt here.  Insurance companies, Medicaid, and Medicare all make their own deals not only with the pharmaceutical industry but also with each hospital.  The hospitals cost shift their debt to the little guy in order to make more profit (the profit they lose on Medicaid and people with no money at all).    They do this by charging people without insurance full price.  This brings up the concept of transparency again.

All this information came out recently in a journal called Health Affairs.  The study analyzed data from 2004 and it showed how the uninsured can become bankrupt by having going into the hospital.  The American Health Association came out against the study saying that it was outdated and flawed.  They claim things have changed.  However, in the study it showed that those that were self pay were charged an average 2.5 times more for hospital services in 2004 than the managed care companies were.  They were also charged three times more than what Medicare paid.  For every $100 Medicare was charged by the hospital, the self paying patient paid $307.  This, by the way, has doubled in the last 20 years.

This is all about negotiation.  There really is no negotiating for the little guy and there never will be unless we all stick together and push for this transparency issued to be resolved.  This will enable the consumer to shop around and force hospitals to keep their prices under control.  In some small way this may actually get people to stop paying exorbitant fees to the greedy managed-care companies and create a better system that is based on the only thing that really counts - cold hard cash.

The whole issue of drug reimportation is back on the table once again.  This is not an an easy dilemma to resolve for many reasons.  Everybody knows I am not a big pharmaceutical industry fan but I do understand that it takes many years and lots of money to develop new drugs.  I also understand that this is a business and I am a big fan of capitalism.  The problem I have is what was pointed out in the Wall Street Journal commentary by a Roger Pilon.  Foreigners pay a lot less for their medications because they're in a socialized system.  That may seem great but we in America bear all the cost in this country for this research and development and the foreigners are what's called “free riders”.  Boy, that sounds like a common theme.

If we allow open access to buying medications from foreign countries we have to guarantee safety.  One thing the Senate is doing is making sure that drug safety will not be an issue and I'm all for that.  As I mentioned before in other Placebo Gazettes, we don't want Aunt Helen getting some medication from Mexico and a few months later growing testicles and therefore becoming Uncle Henry.

I was initially concerned that if this bill goes through the pharmaceutical industry would just raise prices in the foreign countries.  This would negate the whole point.  The amendment to the Food and Drug Administration Revitalization Act would prohibit these companies from doing that.  The author in the Wall Street Journal piece thinks this is a major mistake.  He believes the “better answer is to simply lift the re-importation ban from a limited number of developed countries and let the market play out".  I don't know yet if I agree with him but he brings up some interesting points.  If it eventually lowers prices here in this country then I think it's a good thing.  I still think, however, that we rely too much on big-name drugs when we can get away with generic medications in so many cases.  This, in itself, could bring down the prices of non-generic medications all by itself.

 

Well, it's that time again.  We are pushing forward on our next issue of the Placebo Journal.  If you want to submit any humorous and true story so we can publish it (and get a free subscription) than do so quickly at the link below:

http://placebojournal.com/shopcontent.asp?type=submitstory

I really believe this is going to be another great issue for us.  We have another interview with a famous physician, Dr. Tess Gerritsen, who is a New York Times best-selling author of medical thrillers.  She is from Maine and I know her pretty well.  More importantly, she has a great sense of humor and is a Placebo Journal fan.

If you want to guarantee that you will make the next issue of the funniest medical journal ever created then click below:

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Lies, damn lies, and politicans who don't understand statistics

According to Senator Ron Wyden (D-Oregon) "Americans spend in excess of $2.1 trillion on healthcare or enough to hire a $200,000 physician for
every seven families."

This is a concept whose time has come. I am willing to treat 21 families
and become a millionaire. The only catch is that all those doctors will
not have any:

1. Drugs to prescribe.
2. Laboratories to send tests to.
3. Hospitals to admit to.
4. Nurses, PAs, NPs, etc to help them.
5. Imaging.
6. Cath labs.
7. Operating rooms.
8. Etc.

Talk about stupid and meaningless statistics.

5. Hoax?

One of my readers here at the Placebo Gazette pointed out an article to me from a group called Public Citizen.  I have known about this organization for quite awhile and I'm not their biggest fan.  I think they are very extreme in their methods in which they criticize the government, the president and the pharmaceutical industry.   I know that sounds weird coming from me but I think they push the envelope more than they need to.  Their latest endeavor is calling the medical malpractice crisis a "hoax".

The article is very long and I'm going to leave the link here for you to read.  I'm very curious on your thoughts and I hope you would either put them as a review to this Placebo Gazette or place them on our blog http://placebojournal.blogspot.comwhere you will find this article as well.

http://www.citizen.org/publications/release.cfm?ID=7497&secID=1720&catID=126

A couple concerns I have right off the bat is that my hunch is Public Citizen is anti-physician.  While I agree that there are a very small minority of physicians that cause a lot of malpractice claims it does not prove to me there isn’t a malpractice insurance crisis.  The group seems to want to nail every physician may can for any mistake that happens.  I have read too many personal e-mails to me explaining the travesty of our court systems and what it does to physicians to take this article by Public Citizen seriously.  If you read other mainstream medical journals such as Medical Economics you will find personal stories that are horrifying.  Doctors have been sued many times for no reason at all in shotgun style lawsuits; all of which had driven these doctors to quit the profession or to lose their ability to care.  To me, this is the worst outcome that has happened over the medical liability issue.  I await your thoughts.

6. Bad Name

The New York Times has reported how some physicians are getting paid hundreds of millions of dollars in rebates for prescribing the erythropoiesis-stimulating agents Aranesp, Epogen, and Procrit.  One example showed that a

practice of six oncologists received $2.7 million from one manufacturer for prescribing $9 million worth of its drugs in 2006.  As one of my friends said to me after reading this, “We get chastised for a free lunch and oncologists are getting cash? We are so fu@ked!”  I agree.  This makes all doctors look bad. And the lunches that we get suck anyway.

There have also been studies showing that dialysis centers and hematology/oncology centers that have patients with insurance use much more of the EPO drug than those who have indigent populations.  This story is not over as more information will be coming out.  Like that old saying, “Pigs get fat but hogs get slaughtered”.  This whole thing is pretty sad. 

7. Joke of the Week

A 90-year old man said to his doctor, "I've never felt better... I have an 18-year old bride who is pregnant with my child. What do you think of that?"

The doctor replied, "I have an elderly friend who is a hunter and never misses a season. One day, he was in a hurry and picked up his umbrella by mistake. When he got to the creek, he saw a beaver. He raised his umbrella and went "bang, bang, bang", and the beaver fell dead. What do you think of that?"

The 90-year old said, "I'd say somebody else shot the beaver."

The doctor said, "My point exactly."

For those of you that do medical lectures at conventions, grand rounds or at medical schools, we have the lecture slides that will make your audience smile and laugh.  Isn’t it time you stop using the same old Far Side cartoons?  To check them out, click here:

http://www.placebojournal.com/shopdisplayproducts.asp?id=15&cat=Presentation+Slides

9. Bacharach’s Beliefs by Ted Bacharach MD, retired

PP

The meaning of “pp” varies, there is also a question should the letters be small or large. In early childhood the problem is one of control and placement, something which most of us learn fairly rapidly. Most have it under control by age 3 or 4. The problem does not recur in most people until their later years when even starting it may prove difficult and control also tends to fade. For the purpose of this paper I have felt that while the topic is slightly different the “pp” of childhood and its geriatric sequel have some similar undesirable features. The “PP” I feel deserves some consideration is the “Paper Proficiency” that is being applied to the practice of medicine.

Physician as well as hospital performances are being graded on the basis of the generated paperwork. The Practice and the Art of Medicine are complicated and patient management requires some of both these commodities. In our zeal to quantify medical care, we have allowed “efficiency experts” or similarly qualified individuals to set up criteria to grade performance. The opinion of the patient is not considered valid as many patients are overly impressed by their physician or they don’t like the outcome of their therapy.  The result of the application of this “Paper Proficiency” has resulted in reigniting the physician’s desire to come out ahead.

Starting in the first grade the fledgling physician candidate has had to pass tests and all kinds of paperwork hurdles. It is only after he or she has overcome these hurdles that the candidate may finally become a physician. Once this goal was achieved the physician thought he or she had now progressed to the point where they were allowed and even encouraged to think. This may have been true once but today they soon find that success involves filling out the chart in such a manner that the “Paper Proficiency” can be evaluated by an “expert” armed with a set of hard and fast criteria. The application of “Paper Proficiency” and cookie cutter criteria I am sure will soon result in less attention to patients and far more attention to the “Paper Proficiency” that is expected. More time and attention devoted to paper will do little in improving the examination and treatment of real patients who used to challenge us by presenting with complicated scenarios. In our present environment it is better to catalogue the patient in a category of common diseases. The marks achieved by the physician will be much higher for treating a common disease with recommended approved therapy than for treating a less common disease properly.  

10. New Field

It has been pointed out that Botox is having its effects on the Hollywood circle.  It seems that what was all the rage for actresses (and probably actors as well) is now coming back to haunt them.  An article in the WSJ about this phenomenon can be found here:

  http://online.wsj.com/article/SB117581787173761618-email.html

The bottom line is that these people need to show their emotions in order to perform their craft.  With Botox, however, they have difficulty smiling, frowning or furrowing their brow.  This leads me to believe that a new field will open up to us physicians.  We are going to be called on to inject a substance called Emotox (my invention) which will enable them to express themselves in certain scenes.  Sure, this might not work for everyone (Sofia Coppola in Godfather III comes to mind) but it is a glimmer of hope for those of us physicians who can’t seem to get paid for doing real medicine.  Actually, strike that.  More likely the Hollywood special effects people will come up with animatronic-like electrodes to place under the make-up of these people to make them cry or smile from afar.  Well, it was a good dream while it lasted.

11 Sarita’s Stuff by Sarita Salzberg MD

Did you notice the umpeenth article about antibiotic resistence over the past several months in the AMA News last month?.  It talks about how doctors are inappropriately prescribing antibiotics "but don't blame the doctors too much...they are frustrated there aren't good treatments out there for sinusitis" ....Then, in the JAMA that arrives at the same time, it talks about how JCAHO is admitting that the 6 hour door to drug antibiotic for pneumonia standard may be encouraging physicians to "shoot from the hip" and just prescribe an antibiotic rather than hurt the "quality" statistics for their hospital.  Gee, I wonder if there is a connection here?

The sad thing is that antibiotic resistance is something that is becoming increasingly real in our offices.   In my office,  it is becoming fairly common to see MRSA infections from what folks think are "spider bites" that don't go away.  And we see more and more health care workers getting these infections.  Most of us reading this have been exposed to MRSA and well, what can we do?

It is easy to blame the physician who overprescribes...on the other hand, patients get very, very upset when an antibiotic responsive infection is "missed."  I recall, in pre-9/11 times, when a gentleman called a clinic where I worked and threatened to "blow up the clinic" if he didn't get an antibiotic called in.  At another clinic, a dad went ballistic and accused one of my colleagues of malpractice when he didn't prescribe antibiotics for his daughter’s strep infection.  It was negative on the rapid strep and positive on the culture.  These are very threatening experiences -- but the more common one is for a patient to complain to the powers that be, or simply feel upset that they aren't being taken seriously. 

My parents were antibiotic hoarders.  Their motto was "It wouldn't hurt."  They had their "stash" of Ceclor, Amoxil, Erythromycin, and Zithromax.  When I went to medical school and told them about antibiotic resistance, their response was: "I don't care, I still think they help me.  What?  You're not going to help us out with antibiotics when your a doctor?" And I know why they did this:  They were working people with kids who frequently got sick -- taking time off work meant possible job loss and they simply did not have time to be sick.  These antibiotics had a tremendous placebo effect -- just being there meant that they didn't have to take time off work to go to the doctor until the stash ran out or "didn't work."  And the worst of all was if they went to the doctor who didn't give them an antibiotic -- "That's the reason I went there because I've already tried hot tea, steam and all that crap."  Everything except taking more than a day off work because they simply couldn't do that.

During residency, when I had decent access to antibiotic samples, I developed a "stash" -- but quickly realized that they don't help when you need to rest and use common sense.  "But I don't have time to be sick!!" Unfortunately, antibiotics seem to promise us less sick time -- but it is a scam.  I was sick much of the time with 100+ hour weeks, exposure to people coughing on me all the time, and no sleep  -- and the antibiotics didn't do diddly squat. 

What is the solution?  Like vaccinations, antibiotics are a source for great good and harm.  We have the vaccine injury act to compensate patients for injuries from vaccines.  Physician liability is out of the picture.  Vaccines provide a common good of immunity to our society.  Encouraging everyone to get vaccinated, however, will harm a very small number of children and adults each year. 

We need an Antiobiotic Injury Act.  Basically, if a person does not meet criteria for receiving an antibiotic, the health care provider should be able to document this -- i.e. afebrile, no lymphadenoapthy, rapid strep negative -- and have protection for acting in good faith that they do not have a bacterial infection.  Will some patients be harmed?  Sadly, yes.  These patients who have missed infections should get compensated by the Injury Act Fund.   But the vast majority of folks will do well -- like kids with vaccines. If we don't act, soon most of our antibiotics will be useless and great harm will result from "superbugs" that we have created with the incentives in our system. 

Better than the Antibiotic Injury Act would probably be for people to have reasonable expectations about viruses, illness and that, even if our jobs don't want us to be sick, we all need "time to be sick."  Even  better would be a system where doctors could truly build trust with their patients so that they had enough time to really examine and treat appropriately.  It is so much easier to write an antibiotic script  -- in terms of patient satisfaction and liability -- that some kind of incentive has to be given to physicians, and patients and employers to accept that viruses are out there, have always been out there, and accept some risk of us missing bacterial infections....What do you readers think?  Or should we just continue in the current system, ignoring the elephant in the room of physician liability and patient complaints, and just write for Placebobid?

SUPPORT BACTERIA -- ITS THE ONLY CULTURE SOME PEOPLE HAVE!!

We will be naming the winner of the second annual Tenesmus Award this June.  For those that don’t know, we are looking for those people who have had the guts to fight back against the healthcare system and make them quake in their boots.  Last year’s winner was Judge Janis Jack from Texas who hammered the bogus silicosis lawyers. 

Who do you think should win this year?  Maybe it is a doctor that takes on an HMO?  Or a nurse who drills her crooked hospital administration team?  Maybe it’s even a lawyer who is fighting the good fight?  It doesn’t matter.   Send their information our way and let us reward those who deserve it. 

So far the nominees are:

• John Stossel for his book, "Myths, Lies and Downright Stupidity: Get out the Shovel” where he creams malpractice attorneys.   http://www.placebojournal.com/shopexd.asp?id=204

• Governor Linda Lingle of Hawaii who vetoed a bill to ban the use of thimerosal in pediatric vaccines.  http://www.placebojournal.com/shopexd.asp?id=196

• AMA President William G. Plested III, MD (I call him “Paco”) for ripping on the whole P4P fad.http://www.placebojournal.com/shopexd.asp?id=205

• Philip Howard, a lawyer and chair for an organization called Common Good, who espouses on Specialized Healthcare Courts. http://www.placebojournal.com/shopexd.asp?id=204

• Justen Deal, a Kaiser Permanente employee, who was fired after he criticized the HMO giant’s $3 billion investment in their Electronic Medical Record system.  http://www.placebojournal.com/shopexd.asp?id=210

PLEASE EMAIL ME BACK ON WHO YOU THINK SHOULD WIN!

13. Feedback About The Placebo Gazette

All future feedback will be posted as reviews for each issue.  Please go below and post your thoughts under the WRITE A REVIEW section.  You can also see some of these articles (as well as a whole bunch of other ones) on our blog:

Until next time, keep smiling, keep laughing and keep out of the sample closet.

Doug

King of Medicine