1. Happy Thanksgiving
2. A Spoonful of Hylira
3. I Thought I Was Bad At Reading X-rays
4. Placebo Journal Update
5. Mental Illnesses In Children
6. Smarter Than Me
7. More Doctors Are Quitting
8. Medical Joke Of The Month
9. Gorback’s Thoughts by Michael Gorback MD
10. Unions Get Involved
11. Foreign Accent Syndrome
12. Nice Warmhearted Stories
13. Holiday Season Coming Up
14. Feedback About The Placebo Gazette
1. Happy Thanksgiving
I want to thank you, my readers, for your continued interest in the Placebo Gazette and Placebo Journal. I truly appreciate the feedback you have given me over the years. As Thanksgiving approaches I also want to thank:
- My family, who puts up with all my projects, hobbies and crazy ideas
- Gordon Marshall, who does an incredible job will all the graphics in the Placebo Journal
- Michael Gorback, Sarita Salzberg and Vance Lassey for all their great work in making the Placebo Journal funny
- Bruce Halford, Jeff Mackler, Mark Cole, Jeff Freeman and his wife Becky, who are helping me get the screen time I pretend to deserve
- My medical partners and employers who somehow allow me to keep the Placebo Universe going
CLICK HERE TO COMMENT
2. A Spoonful of Hylira
Alex: Carbofed, Hylira, Andehist and ICAR
Me: What are drugs that I never heard of?
Alex: Yes, but that is not the answer we were looking for. The answer we wanted was "what are old medications that Medicaid has paid over $200 million for since 2004". Let's see what you risked.
Me: Everything.
Alex: Ahhh...that's a shame. Good having you with us.
Me: Can I get a free home game?
Alex: No
The story about the older "grandfathered" medications still being paid for by Medicaid is an interesting one. It shows that bureaucracy is still alive and well. It shows that making any changes to Medicaid will occur at a snail's pace. It shows that our government still pisses away money for no good reason. And it also shows that this Senator Grassley is a hard ass and that is a good thing. It doesn't explain to me; however, who these doctors are who are prescribing these outdated meds? Maybe someone can do a little extra investigation to see if they are worthy of keeping their licenses? This sounds harsh but it makes you wonder if we should be worried. No one wants to take away the driver's license from their little old lady patient until you see her driving on the sidewalk and by then it could be too late.
For those not in the know, Carbofed is for colds and flu, Hylira is a dry skin ointment, Andehist is a decongestant, and ICAR Prenatal is a vitamin tablet. Medicaid data show the program paid $7.3 million for Carbofed products from 2004 to 2007; $146,000 for Hylira; $4.8 million for Andehist products, and $900,000 for ICAR. In actuality, these amounts of money are peanuts when examining how much is wasted by the government's Medicaid program. I am just thankful that someone is starting to look.
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3. I Thought I Was Bad At Reading X-rays
Dr. Michael Kelly of Michigan has been finding asbestos related diseases on x-rays for the past 15 years. In fact, he has such a keen eye for it that he has found 7,323 cases. Coincidentally enough, Michigan accounts for nearly 14% of all asbestos lawsuits. They are number one for new filings in 2007. Also what may seem like a coincidence is that Dr. Kelly has been getting paid $500 for every person he has screened for the disease. That's over $3.5 million in just the ones he found positive. He probably made a lot more than that. He must be a great radiologist? Turns out he is not.
Dr. Kelly is an occupational physician and an internist. In the cases where the x-rays were sent to a hospital to be read by the radiologist, 88% of them were read as normal. Whoops. A blind study of 68 cases sent to Dr. Kelly was also read using independent radiologists and they only found one case of an abnormality. Dr. Kelly found 88% of those 68 to be abnormal. Call me a nut but something seems odd here.
Either Dr. Michael Kelly is just stupid or crooked. I am not sure which is the better answer to pick. The evidence finally overwhelmed the judge who has been seeing asbestos cases in Michigan since the early 1990s. He decided to have a hearing on good old Dr. Kelly but the plantiffs' attorneys pulled out from all but one of the lawsuits. That's weird?
Here are some questions to ponder:
- What about the thousands of patients Dr. Kelly has diagnosed in the past? Are those court cases to be reopened?
- Does Dr. Kelly at least get investigated by the state board of medicine? It sure seems that this one is actually appropriate versus their typical cases of punishing a doctor for dropping an F bomb in public, etc?
- Can or should Dr. Kelly be sued by all the defendants he screwed in the past?
- Will Dr. Kelly go to jail for perjury or fraud?
- If no to all of the above, can I get a job like Dr. Kelly's?
For more answers, tune in next time to As The Malpractice Cases Churn.
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4. Placebo Journal Update
Hurry! You have until the Nov 30th to make it in time to subscribe for the December issue of the Placebo Journal. Check out our some hysterical true stories as well as:
-
Spermo - the online physician in-vitro matching servie
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Rejuvenescence - a medical conference that will change your life
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The Administrators - Broadway's newest farce
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And much, much more!
If you are interested, and I hope you are, just click below:
SUBSCRIBE
5. Mental Illnesses In Children
We are blessed to have some really good child psychiatrists here in central Maine. That being said, it is almost impossible to get kids in to see them. This is not a knock on them at all. They are just overwhelmed. The vetting process whereupon each referral is screened is pretty intense. What that means is that any garden variety mental illness for a kid is pushed back to us primary care folk. As if any mental illness in a kid is garden variety? Maine is not alone in need for help in this area. A recent report surveying state and county mental health officials states adequate mental health care is appropriate in only one in five states. Even those states still have very long waiting lists. The answer has been to thrust that responsibility onto the schools and primary care doctors. Boy, that seems like a common theme, huh? To be honest, I am okay with seeing kids with these problems. I think I am pretty good at it. I just need to have the adequate time to spend with them. Oh, it would also be nice if the insurers, Medicaid, etc. would compensate appropriately for this extra time. A man can dream, can't he?
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6. Smarter Than Me
Here is a cool story that came out in the Washington Post. A young woman was diagnosed with an ependymoma by a family doctor at the student health center. She had gone in with symptoms of morning nausea and vomiting that went away as the day progressed. She had seen her regular doctor a few times and then even saw a gastroenterologist. The specialist did an endoscopy and found no cause for her symptoms. As the story goes, the patient saw a different family doctor who was filling in and he "magically" knew what was going on. Within minutes he diagnosed her and got her admitted to the hospital where it was found she had a brain tumor.
There is something that didn't sit right with me as I read this. Don't get me wrong, as a family doctor I do like to hear stories where my brethren is a hero but the article states that the patient saw this new doctor and within "minutes after examining her" knew what was going on. Later, the doc says,"one of the things they teach you in medical school is that if you just take the time to listen to patients, they'll tell you what's going on." Maybe. I am not so sure he actually took all the time in the world (minutes?) or something intuitively clicked that clued him in. If you ever read the book Blink then you know what I mean. We are also taught in medical school that when you hear hoof beats then you should think horses, not zebras. In other words, common things are common and not every case of nausea should lead us to order an MRI of the brain.
Another issue with this piece is that is makes the other doctors seem incompetent, rushed and non-caring. I am not so sure they were. The patient was initially seem in November of 1999. By the time she saw the family doctor at the end, she had been through medical management, specialist referral, and endoscopy. That was all done by April 2000 which was five months total. That really isn't too bad. New symptoms had arisen as well which was not available to the first doctor. She had lost 10 pounds, was having visual trouble, and was so weak and frail that she couldn't even do the laundry. This gives the "new" doctor an advantage and probably helped him in his diagnosis.
My point is that the way this story is told makes some very qualified professionals look bad. I love that the family doctor is put on a pedestal here but we all can't be House. That is for television which is where this story will eventually end up. I, too, would have missed this diagnosis at first. I don't always have the luxury of time but it wouldn't have mattered as her initial symptoms were common and nebulous. Hopefully with good follow-up I would have picked up on this zebra as well. That is the real advantage and benefit of seeing your primary care doctor. That's what makes us so important to our healthcare system.
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7. More Doctors Quitting
A survey conducted on primary care doctors by the Physician's Foundation found that:
- Sixty percent would not recommend medicine as a career
- Nearly half of them are going to cut back or quit medicine entirely
- Seventy-eight percent of those who answered believe there is a shortage of primary care doctors.
- More than 90 percent said the time they devote to non-clinical paperwork has increased in the last three years and 63 percent said this has caused them to spend less time with each patient.
- Eleven percent said they plan to retire
- Thirteen percent said they plan to seek a job that removes them from active patient care.
- Twenty percent said they will cut back on patients seen
- Ten percent plan to move to part-time work.
- Seventy six percent of physicians said they are working at "full capacity" or "overextended and overworked".
Primary care is the engine that runs the healthcare system in this country. No plan will ever work unless we make this specialty more palatable. Case closed.
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8. Medical Joke of the Week
| The Faith Healer |
Two women were sitting in the doctor's waiting room comparing notes on their various disorders.
"I want a baby more than anything in the world," said the first, "But I guess it is impossible."
"I used to feel just the same way," said the second. "But then everything changed. That's why I'm here. I'm going to have a baby in three months."
"You must tell me what you did."
"I went to a faith healer."
"But I've tried that. My husband and I
went to one for nearly a year and it didn't help a bit."
The other woman smiled and whispered, "Try going alone next time." |
9. Gorback’s Thoughts by Michael Gorback MD
A Very Dangerous Decision
In Cassanese v. United Health Care a federal court upheld United Healthcare's denial of pain medication because it didn't have FDA approval for chronic pain was considered "experimental". We've all seen this BS from the insurance companies but now it has the Federal Court Seal of Approval.
This is pure hypocrisy. In reality they don't give a rat's ass about FDA-approved uses, just the cost. If Fentora was 10 cents per dose they wouldn't care if the patient washed his hair with it. This is their new ploy to deny care and feed the bottom line.
This is a very dangerous decision for patients in general and pain sufferers in particular because there is no definitive study showing benefit of narcotics for chronic non-cancer pain, and there are only a few non-narcotic drugs that have FDA-approved uses for pain. Even then, they split hairs. If a patient has nerve pain due to diabetes, then he can get Cymbalta because it is FDA-approved for diabetic neuropathy. If the nerve pain is due to anything else they deny Cymbalta as off-label but they allow off-label use of gabapentin. What's the difference
between off-label use of Cymbalta and off-label use of gabapentin? Gabapentin is generic and therefore cheap. It's not the FDA approval or patient well-being, it's about the bottom line.
A lot of medications are used off-label because the FDA-approval process is money-driven. A drug company is not going to pursue FDA approval unless there's a buck in it. Why did the maker of Lyrica pursue an FDA indication for fibromyalgia but not non-diabetic nerve pain? There's a lot of money in fibromyalgia. Why don't the makers of gabapentin seek approval for its use in fibromyalgia? Because the manufacturer of a generic drug won't spend the millions of dollars on a study when (1) the profit margin is so low and (2) their competitor would benefit just as much from the results.
To our patients: Are you taking a baby aspirin every day to prevent heart attacks even though you have no known heart disease? Off-label use. If aspirin was
$1/pill and you wanted your insurance to pay for it they could deny it. Another example is the class of drugs called ACE inhibitors. These can reduce the risk of kidney damage in diabetes. Off-label use, once again. Your insurance company could deny it under this decision.
The insurance companies are going to have a field day with this and it could bomb pain management back to the Stone Age. With a federal decision supporting them, the insurers can deny almost any chronic pain medication they care to. This will be "good" for pain doctors because then we will have to implant hideously expensive gadgets like spinal cord stimulators instead of doing a monthly medication visit for $20. Of course, when the carriers deny those implants, the patients will basically be back in the 1980s again with no relief for their pain by any means.
It's all about the money, not the poor suckers who thought they had health care coverage after spending hundreds of dollars/month on premiums. I hope there's a special circle of Hell reserved for the people who make these decisions and for the politicians who have allowed the insurance companies to run the healthcare system for the past 15 years.
The plaintiff in this case blew it. They should have shown that United bases their off-label decisions based on cost, not FDA approval. That's a no-brainer.
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10. Unions Get Involved
Change to Win, a group of unions that represent about 6 million workers, is going after the PBM (Pharmacy Benefit Manager) that does its dirty work for CVS. It seems Caremark has been sending letters to doctors prodding them to add Januvia to specific patients' treatments. How is that for patient privacy? The letter tells the physician how CVS went through a thorough review process to identify which patients would benefit from the switch. It also states at the bottom that Merck, which happens to make Januvia, paid for the whole thing. Januvia seems like a good drug. It may be a staple in the oral treatment of diabetes type II in the future. It's just really expensive. This type of marketing, though, is outrageous. With this information coming out in the WSJ, all groups involved are now trying to pass the blame. Merck is now saying that the letter was sent by Caremark and they were just trying to help patients and doctors. CVS, which owns Caremark (one of the nation's largest PBM) claim they weren't trying to switch patients medications. They also claim this was about the unions wanting to get back at them in a dispute about workplace rules. The only ones not saying anything are the patients and doctors who get caught in the middle like pawns. I get tons of these "reviews" all the time and it just adds to my paperwork burden. As much as I really don't like strong arming unions, I am kind of glad they are pissing off the PBMs. That is until they get some type of deal they want and then all of this will mysteriously go away.
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11. Foreign Accent Syndrome
I had to share this ludicrous story with someone. It was reported in the news as if the medical condition is real. A 50-year-old woman began speaking in a "strong European accent" though she has never been out of the United States. The case was even featured on a Discovery Channel show! Supposedly, only 50 or 60 cases of "Foreign Accent Syndrome" exist. Really? Personally, I am not buying this. I mean if the lady started speaking a foreign language then I would be more intrigued. Calling this a medical disorder, however, seems a little over the top. I may be going on a limb here but wouldn't you call someone who spontaneously starts speaking with an accent....... an ACTOR! And I believe there have been millions of them over the centuries. Some are better than others. Acting isn't deadly (most of the time). Acting isn't contagious. And acting isn't a disease.
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12. Nice Warmhearted Stories
The media recently put out some nice warmhearted stories that really makes you feel good inside. The first is the Ohio woman who gave birth to her own triplet granddaughters. The real mom couldn't do this due to a hysterectomy and so in vitro fertilization was performed. Unfortunately, the babies were born 2 months early and weighed less than three pounds. Congratulations to mom, dad and grandma!
The next story comes out of the pharmaceutical research world. The JUPITER study showed that using Crestor, a cholesterol drug, to treat people with normal cholesterol cut the risk of heart attacks, strokes and premature death in half. Wow! This is amazing news. Sign me up.
These two little diddies mentioned above seemed wonderful at first glance until one digs a little deeper. The first story about "Grandma Surrogate" sure cost someone a whole lot of money. Her daughter already had two children from a previous marriage but I guess she really needed those triplets in her life. That is fine and dandy with me. Hey, have as many as you want. Who is paying for it, though? The IVF probably cost upward of $100K. That would be chump change compared to the premies that are vacationing in the NICU for two months. We are looking at millions. That is a whole lot of immunizations to spread around the country. That is a whole lot of blood pressure medications for people who can't afford them.
The second story seems like we have the newest and greatest pill that should be put in the water supply. But hold on. About 7 billion people would qualify to follow the JUPITER protocol which, at a cost of $116 a month, would put us back almost $10 billion. That would prevent 28,000 heart attacks, strokes, etc. In other words, in order to save one life it would cost us about $500,000. Ouch.
What seems so sweet and nice on the outside may be hard to swallow once you dig a little deeper. We DO NOT have the money to pay for all this. The truth is that someone has to make hard calls in the future which would put the kibosh on both these stories. That is called rationing. That is called reality.
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13. Holiday Season Coming Up
It is getting to that time of year again. Before you start stressing out about what to get your friends and loved ones, remember that we have some unique gifts you may want to look at:
· Placebo Journal subscription
· Humorous medical posters
· MRSA T-Shirt
14. Feedback About The Placebo Gazette
I WANT TO KNOW WHAT YOU THINK. Please go to each individual story and follow the link the Placebo Journal Blog. If you do not have access to the blog you can also post your thoughts under the WRITE A REVIEW section.
Until next time, keep smiling, keep laughing and keep out of the sample closet.
Doug
King of Medicine
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