Last time I informed you that the complaint that drug company greed was driving up the costs of drugs was actually untrue, and that it was actually part of a coordinated campaign of lies and manipulations by certain individuals. I then specifically identified this group as being the Democratic Party. Now I will explain the reason for all of this.
The purpose of the manipulation is, of course, to serve as a means to a particular end, in this case more power. Power over other people's lives. The only kind of power that means anything in the political world. Many people think that the end is money, but to these people, money is just another way of wielding power.
This is how the manipulation works: If I can get you upset enough about the "fact" that somebody (else) is taking advantage of you, I can get you angry enough to demand change. If I can get enough people angry enough, then I can create a force for change. And if I have been the one creating the upset, anger and now the force for change, I can suggest the alternative improvement that will fix the problem. And naturally, that solution will ultimately leave me and those like me in charge of ever increasing portions of your life, giving me more and more power over you. Yes, the power that these people want is not the power to change things, it is the power to control you.
In this case, the lie is that the drug companies make too much money, and they make it at your expense. This leads to the upset, and makes you angry. When enough people are angry enough, then they propose the solution -- price controls, managed care, a government controlled Medicare Part D, et cetera. Once they control these things, they can tell you which drugs you can and cannot take (via formularies), thus controlling another little part of your life.
When did this begin? And why do I blame only the Democrats? The seeds were likely planted long ago, but this particular manipulation became blatantly apparent during the Presidential campaign of 1992. During this campaign, Bill Clinton strapped a saddle onto the backs of the drug companies, hounding them (and of all of healthcare only the drug companies) about their prices and their "obscene" profits. He rode the drug companies into the White House. But then he made a big mistake.
Instead of trying to bend to his will the force he had created against only the drug companies, he tried to use it to control all of healthcare by proposing the Clinton Healthcare Plan (aka "Hillary Care"). This plan was a none-too-thinly veiled attempt at a government takeover of the insurance industry. But the American people had not been made angry at the insurance companies, so they wisely stopped this plan in its tracks.
Today, the public at large are finally (and more appropriately) being made angry at the insurance companies, who actually are making obscene profits, enough to make the oil companies jealous. And there are those in the political world ready to offer their radical solution.
A single-payer government healthcare system. Government control over every aspect of your healthcare.
Keep in mind that the only healthcare system that the government knows how to run is the VA Medical System. (Medicare is actually an insurance plan, not a medical system.) The VA system is for all intents and purposes a staff model HMO. Managed care. And managed care saves money in only two ways: rationing and cost shifting.
Why blame only the Democrats? It was they that rode the pharmaceutical industry into office. It was they who tried to take over the health insurance industry. And it is only among the Democrats (and a few fringe liberal groups) that one hears the call for a single payer system.
Hopefully the American people will keep their wisdom and kill this idea also. But I'm afraid, very afraid, that the manipulation this time will succeed.
Saturday, August 19, 2006
Wednesday, August 16, 2006
Think The Drug Companies Are The Problem? Think Again
Once again it's time to get back to the task of discussing why medicines cost so much. Or in this particular case, why they don't, though you think this is a reason that they do.
If you were to go out on the street and ask people why they think their medicines are so expensive, I suspect the most common response would be something like "Because the drug companies are too greedy!" And it's not surprising that they would blame the drug companies. After all, that's what they've been told is the main problem for years. Unfortunately, what they've been told for all these years is a fabrication. A fabrication constructed for one and only one ultimate purpose -- manipulation to an end.
Now, regular readers here (I am egotistically assuming that there are some regular readers despite the lack of evidence to support this) have already learned about my belief that some things in medicine are done for non-altruistic, power-seeking purposes (see "Medicare Part D Delenda Est!"). This is another one of these purposes.
We have all been led to believe that the drug companies greedily seek exorbitant profits, and that this is what is the major force behind the escalating cost of prescription medicines. This is not really the case. The corporate profits of the drug companies, after expenses including R&D, is no higher and really no lower than that of your average large corporation. (I will fault the drug companies, however, for trying to hide behind the argument 'we need these profits to fund R&D'. R&D is a business expense, everybody else considers it a business expense, you guys consider it a business expense, no one else is ashamed of it and you shouldn't be either.)
The purpose of this fabrication takes a little explanation. In the current twisted field of medical reimbursement, the vast majority of people have no idea what their medical care costs. Medicare or Medicaid or managed care or an insurance company foots the bill, and all most people ever see is the co-pay, if that much. Those few who look at their bills think they are getting a great benefit from how much their doctor charged and got paid by the payor, never realizing that the doctor really only got paid some small percentage of his charges and the rest went away as a "contractual write-off". (This issue itself is another reason I'm nigh on to postal, but that's a different rant.)
Medicine costs are a different matter. Most people either pay for their own medicines or pay a much higher percentage of the costs of their medicines, so they are much more sensitive to this cost. This makes it an excellent target for manipulation. And there is one group that excels at manipulating it.
Some would call this group "liberals". I think this actually maligns some liberals, as little as that is possible. I am more willing to focus down to who it really is that is doing the manipulating with this fabrication, and I am willing to name names.
It is the Democratic Party.
But what is the purpose of this kind of manipulation? What is the goal? What power am I talking about?
More in my next post.
If you were to go out on the street and ask people why they think their medicines are so expensive, I suspect the most common response would be something like "Because the drug companies are too greedy!" And it's not surprising that they would blame the drug companies. After all, that's what they've been told is the main problem for years. Unfortunately, what they've been told for all these years is a fabrication. A fabrication constructed for one and only one ultimate purpose -- manipulation to an end.
Now, regular readers here (I am egotistically assuming that there are some regular readers despite the lack of evidence to support this) have already learned about my belief that some things in medicine are done for non-altruistic, power-seeking purposes (see "Medicare Part D Delenda Est!"). This is another one of these purposes.
We have all been led to believe that the drug companies greedily seek exorbitant profits, and that this is what is the major force behind the escalating cost of prescription medicines. This is not really the case. The corporate profits of the drug companies, after expenses including R&D, is no higher and really no lower than that of your average large corporation. (I will fault the drug companies, however, for trying to hide behind the argument 'we need these profits to fund R&D'. R&D is a business expense, everybody else considers it a business expense, you guys consider it a business expense, no one else is ashamed of it and you shouldn't be either.)
The purpose of this fabrication takes a little explanation. In the current twisted field of medical reimbursement, the vast majority of people have no idea what their medical care costs. Medicare or Medicaid or managed care or an insurance company foots the bill, and all most people ever see is the co-pay, if that much. Those few who look at their bills think they are getting a great benefit from how much their doctor charged and got paid by the payor, never realizing that the doctor really only got paid some small percentage of his charges and the rest went away as a "contractual write-off". (This issue itself is another reason I'm nigh on to postal, but that's a different rant.)
Medicine costs are a different matter. Most people either pay for their own medicines or pay a much higher percentage of the costs of their medicines, so they are much more sensitive to this cost. This makes it an excellent target for manipulation. And there is one group that excels at manipulating it.
Some would call this group "liberals". I think this actually maligns some liberals, as little as that is possible. I am more willing to focus down to who it really is that is doing the manipulating with this fabrication, and I am willing to name names.
It is the Democratic Party.
But what is the purpose of this kind of manipulation? What is the goal? What power am I talking about?
More in my next post.
Saturday, August 12, 2006
God Sent Me A Kittycat and His Name Was Toby
Toby was born sometime in 2003; the exact date is known only to his littermates. He died on July 23, 2006 after a lengthy illness. He is survived by his owner, PostalMed, and his constant companion, Tyler. Services were held at a private cemetery belonging to the family.
I lost my friend on July 23 of this year. Already you are probably wondering what this has to do with anything medical, but I'll come to that. But you need a little backstory first.
I have had a few dogs in my life before, but never a cat. I was a dog person; cats were inferior creatures. And all three of my previous dogs had had good, full, long lives. In October 2003 I had been without a pet for some period of time. And then a cat found me. Or rather, God sent me a cat.
One morning I awoke to find a half-grown scrawny cat clinging to the window screen of the breakfast nook like one of those Garfield dolls you've seen stuck to the inside of car windshields. The breakfast nook window faced out onto the covered back porch. Nothing I could do over the next few days could persuade this cat to leave. I swung a broom at him (no, I did not hit him with the broom; I reserve that to those of the human persuasion); I tossed him out into the rain; I tried yelling and other loud noises. He would occasionally wander off but every morning there he'd be, either clinging to the screen or sleeping in an empty flowerpot on the porch. "Well," I figured, "he'll leave when he gets hungry enough." One morning he wasn't there. But wait, there he was, crawling headfirst down a tree in the backyard!
After almost two weeks of this, I couldn't take it anymore. I tossed him a slice of ham (which he promptly dashed off with). Okay, he could be the porch cat. That lasted for about a week, till the first time it got cold. Then in he came. He got a bath and a trip to the vet to check him for disease, but except for some intestinal parasites, he checked out clean from all the usual cat ailments. After about another month I figured it out; his name was Toby. (I have always believed that you don't name a pet; you wait till it tells you (by its personality) what its name is.)
For the first year or so, everything was grand. He played, he ate, he pooped (always in the litterbox; he took to it instinctively), he slept and he slept some more. He grew and became a sleek, sophisticated, elegant, almost professorial cat. He almost never made noise and his meows were quite soft. He tossed his own featherball and then chased it down. He made sure my alarm clock woke me up by crawling under the covers and attacking my feet. He occasionally decided to give my hair an impromptu grooming. (He had a thing about hair, the longer the more fascinating.) He chased the laser pointer to the point of exhaustion. He hid in the laundry sink when my great niece came to visit. And he finally learned to purr, although so quietly you had to almost have your ear in front of his mouth to hear it.
In late 2004 things began to change. He slept more and more. He didn't eat as much. Ultimately he stopped eating altogether. He lost weight -- lots of it. After exhaustive testing (if you knew how much that all cost you'd realize just how postal-crazy I am!) we had an answer. Toby had feline leukemia virus (FLV for short). On his initial vet visit he had tested negative for this and he had been vaccinated, so this wasn't the first thing we checked. And he had never been exposed to any other cats since he had acquired me. FLV has a window period (like another virus we all know and fear), and we had missed it the first time around.
By this time Toby had lost about one-third of his body weight, so nutrition was paramount. Have you ever force-fed a cat? It's an interesting process. Through perseverance and with time Toby regained his weight. And after almost seven months of force-feeding, he began to eat on his own again. We had turned the corner -- Toby would live! But some of his blood counts remained low and his FLV test remained positive. The vet was somewhat less than cautiously optimistic.
For about 9 months Toby did fine. Then he started losing weight again, and quit eating. But this time it was different. The weight loss was rapid, and he actually felt thinner and more fragile than the measured amount of weight loss would indicate. Over the July 4th holiday, he started getting short of breath. So back to the vet he went.
It took the vet only a couple of minutes to discover that Toby had a pleural effusion, fluid trapped between his lung and chest wall, and it was smothering him. The vet removed 250 mLs of fluid (for a cat this is enormous), and then he could breathe better. Analysis of the fluid suggested the cause was heart failure. So we put Toby on Lasix and started to force-feed him again and hoped for the best.
Two weeks later, Toby was short of breath again. The fluid had returned. Only this time the fluid didn't look like heart failure. It was the kind of fluid that is usually caused by cancer. The rapid weight loss finally made some sort of horrible sense. My cat was a candidate for hospice care.
I took Toby home. I decided that if he began to suffer I would take him back to the vet for the final time, but I didn't really want to have to do this. But he didn't suffer. He never looked like he was struggling to breathe, though right at the end he did get cyanotic. Two days later, in the early morning hours of that Sunday, God took back the kittycat he had sent me only three years before.
That cat's death after only three years bothered me more than losing three dogs after 14-15 years each. Maybe it was because we fought so hard together to try to beat that virus. Toby died on July 23, 2006. But really I "lost" my cat in late 2004, when he first got sick. Even after his nutritional rescue, when we thought we had turned the corner, he was never the same cat as he was before. He didn't chase the laser pointer anymore; he didn't play with his featherball; he no longer crawled under the covers to attack my feet. And the quiet purr was no more.
Now comes the medical aspect of all this. Feline leukemia virus is a retrovirus similar to another feline virus, FIV--feline immunodeficiency virus, which is a close cousin to that dreaded human virus, HIV. Of these three, FLV was actually discovered first, in the 1960's, and it was the knowledge of its existence and what it does that led researchers to consider that AIDS might be caused by a virus (which we now know as HIV). Despite its name, the vast majority of infected cats do not get leukemia as was thought in the 1960's and 1970's, hence the name. However, FLV primarily causes immunodeficiency and it is this that occasionally leads to leukemia. FIV, which is even closer genetically to HIV, was actually discovered slightly after HIV. But they are all retroviruses, and they all have somewhat similar effects on the immune system.
Supposedly some researchers believe that FLV/FIV could be used as an animal model for HIV, and that discovering how FLV works and how to treat it would benefit human AIDS patients. A Google search for FLV and FLV+ research does not seem to indicate that this is happening to any great extent. One would think that using cats in research would be cheaper than using chimpanzees (which get SIV); however, it does not look like there is a lot of research going on into looking for treatments for FLV.
If FLV/FIV can serve as models for HIV, then it stands to reason that the biggest bang for the buck in research would be by looking for treatments for FLV/FIV and then trying them on humans, but as far as I can tell, it seems that the exact opposite is occurring. Human AIDS drugs are being tried on cats! Unfortunately, the HIV drugs either do not work or are too toxic to be used in cats. (Cats have very sensitive systems; vets have their work cut out for them taking care of cats.)
So far, there has yet to be discovered any effective treatment for FLV. The Internet is full of websites promoting the use of interferon (human and feline), aloe vera, vitamin C, and other so-called immunomodulator drugs (most of which are either herbal or bacterial extracts) but there is precious little evidence that any of this works. Meanwhile cats continue to die, and even the endangered Florida panther is now threatened by this virus.
Our four-footed companions deserve better than this. My Toby deserved better than this. And many humans in the past, present, and future may have benefited had this avenue of research been pursued more aggressively earlier.
Thank you, Toby, for opening my eyes. Cats are not inferior creatures. They are warm, sweet, cute and cuddly, funny and lovable. They are just as important as dogs and sheep and pigs and cows and horses and little white mice. And if we can learn to heal those animals entrusted to us by God, we might just learn how to heal ourselves.
I miss you, Toby. But I know you're waiting for me at the Rainbow Bridge, along with Duchess, Shaggy, and Scooby Doo. It's going to be quite a reunion someday.
Wednesday, July 19, 2006
Bravo! Thank You, Mr. President!
As he had promised, today President Bush vetoed the embryonic stem cell funding bill passed by the Congress and Senate.
In his written statement to the House as he returned the vetoed bill, he said, "If we are to find the right ways to advance ethical medical research, we also must be willing when necessary to reject the wrong ways. For that reason, I must veto this bill."
President Bush could not be more correct with this statement. Science and nature have insurmountable barriers that cannot be violated (e.g., the Three Laws of Thermodynamics, the speed of light). Ethics and morality have barriers that are just as real but are not insurmountable. But just because something can be done does not mean that it must be done, or even that it should be done. Even surmountable barriers often should not be crossed.
In the early part of the 20th Century, the US Supreme Court upheld a law (since struck down) allowing states to sterilize, without the consent of the patient or their family, the mentally retarded to prevent the contamination of the gene pool. Eugenics of this type was considered scientifically rational at that time; today we consider this repugnant -- because we now know better the ethical and moral swamp that that idea leads to.
President Bush later went on to say, "This bill would support the taking of innocent human life in the hope of finding medical benefits for others. It crosses a moral boundary that our decent society needs to respect."
Let me rephrase this in the form of an analogy. Let's say Congress passed a bill providing funding for the use of the bodies and tissues of executed criminals for medical research "in the hope of finding medical benefits for others". I suspect the outrage would be immediate and highly vitriolic.
The only real difference in the two proposals is that the criminals could actually volunteer for this honor, whereas the embryonic humans cannot. And, of course, the criminals are convicted criminals, whereas the embryonic humans are guilty only of being created and unwanted.
The US House of Representatives has already tried to overturn this veto and has failed.
Let no one fail to realize this: the issue of government funding (with the tacit governmental approval that this implies) of embryonic stem cell research has nothing to do with science or treating disease or helping people.
Embryonic stem cell research to date has shown little scientific promise, with limited to no actual benefits ever having been shown and a significant (greater than 50%) incidence of malignant teratoma formation when it has been tried as a therapy. Somatic (umbilical cord or adult, usually bone marrow) stem cell research, on the other hand, which is not barred from federal funding, has shown some encouraging results in early trials, and does not seem to have any significant risk of teratoma formation.
If there was significant promise for treating disease from embryonic stem cell therapies, rest assured the biotech companies would be funneling large amounts of research dollars into doing this research (private funding for embryonic stem stell research is not banned). As it is, the biotech firms are voting with their dollars -- they are not funding embryonic stem cell research. That alone should be telling.
The promotion against all evidence of usefulness of embryonic stem cell research, and particularly the strident demand for federal funding and thus tacit federal approval, has only one motivation. It is the cry of the anti-life crowd (aka pro-"choice") for a stamp of imprimatur for abortion. How such approval leads to any kind of justification of abortion follows an illogical argument that cannot be understood by any truly sentient being, but it is there nonetheless.
Polls suggest that 70% of the American public supports the idea of federal funding of stem cell research. I'll wager that the majority of this 70% does not understand that stem cell research does not have to be embryonic stem cell research. Furthermore, I'll wager that if informed of the fact that the most promising stem cell research is not embryonic, they would insist that the research funding go into somatic stem cell research.
So thank you, Mr. President. Ethics and morals and science are on your side.
P.S. Senator Frist, you are a physician. I cannot believe you do not understand this.
In his written statement to the House as he returned the vetoed bill, he said, "If we are to find the right ways to advance ethical medical research, we also must be willing when necessary to reject the wrong ways. For that reason, I must veto this bill."
President Bush could not be more correct with this statement. Science and nature have insurmountable barriers that cannot be violated (e.g., the Three Laws of Thermodynamics, the speed of light). Ethics and morality have barriers that are just as real but are not insurmountable. But just because something can be done does not mean that it must be done, or even that it should be done. Even surmountable barriers often should not be crossed.
In the early part of the 20th Century, the US Supreme Court upheld a law (since struck down) allowing states to sterilize, without the consent of the patient or their family, the mentally retarded to prevent the contamination of the gene pool. Eugenics of this type was considered scientifically rational at that time; today we consider this repugnant -- because we now know better the ethical and moral swamp that that idea leads to.
President Bush later went on to say, "This bill would support the taking of innocent human life in the hope of finding medical benefits for others. It crosses a moral boundary that our decent society needs to respect."
Let me rephrase this in the form of an analogy. Let's say Congress passed a bill providing funding for the use of the bodies and tissues of executed criminals for medical research "in the hope of finding medical benefits for others". I suspect the outrage would be immediate and highly vitriolic.
The only real difference in the two proposals is that the criminals could actually volunteer for this honor, whereas the embryonic humans cannot. And, of course, the criminals are convicted criminals, whereas the embryonic humans are guilty only of being created and unwanted.
The US House of Representatives has already tried to overturn this veto and has failed.
Let no one fail to realize this: the issue of government funding (with the tacit governmental approval that this implies) of embryonic stem cell research has nothing to do with science or treating disease or helping people.
Embryonic stem cell research to date has shown little scientific promise, with limited to no actual benefits ever having been shown and a significant (greater than 50%) incidence of malignant teratoma formation when it has been tried as a therapy. Somatic (umbilical cord or adult, usually bone marrow) stem cell research, on the other hand, which is not barred from federal funding, has shown some encouraging results in early trials, and does not seem to have any significant risk of teratoma formation.
If there was significant promise for treating disease from embryonic stem cell therapies, rest assured the biotech companies would be funneling large amounts of research dollars into doing this research (private funding for embryonic stem stell research is not banned). As it is, the biotech firms are voting with their dollars -- they are not funding embryonic stem cell research. That alone should be telling.
The promotion against all evidence of usefulness of embryonic stem cell research, and particularly the strident demand for federal funding and thus tacit federal approval, has only one motivation. It is the cry of the anti-life crowd (aka pro-"choice") for a stamp of imprimatur for abortion. How such approval leads to any kind of justification of abortion follows an illogical argument that cannot be understood by any truly sentient being, but it is there nonetheless.
Polls suggest that 70% of the American public supports the idea of federal funding of stem cell research. I'll wager that the majority of this 70% does not understand that stem cell research does not have to be embryonic stem cell research. Furthermore, I'll wager that if informed of the fact that the most promising stem cell research is not embryonic, they would insist that the research funding go into somatic stem cell research.
So thank you, Mr. President. Ethics and morals and science are on your side.
P.S. Senator Frist, you are a physician. I cannot believe you do not understand this.
Sunday, July 16, 2006
Why Medicines Cost Too Much -- Managed Care is the Problem, not the Solution
It's about time I got back to the business of explaining why you feel the need to complain about the cost of your medicines every time you go to the pharmacy instead of my usual unimportant job of keeping my patients alive and healthy. I hinted at this issue in the beginning of my rant about the lawyers draining away the lifeblood of the economy. I believe that managed care (in all of its forms) is not the solution to the problem; rather, it is a big part of the problem itself.
There was a time when I would have considered this the number one force driving up the cost of prescription drugs in this country. However, the behavior of the legal eagles over the past few years has dropped this down to a close second on my list. But it is a close second, and could overtake the lawyers at any moment, especially since the advent of Medicare Part D. (Medicare Part D delenda est!!!)
I can hear the protests from here: "But my insurance coverage saves me money -- all I pay is the copay, when I used to have to pay full price." "But I've always heard that managed care was supposed to save money, not cost more!" What most people don't understand is that managed care is a magician, and a really good one. Through sleight of hand and misdirection, the managed care industry has managed to convince almost everyone that they actually save money and reduce costs. Like most magic, however, this is only an illusion. Managed care may save you money (unless you are paying your own insurance premiums!) and it definitely saves money for the insurance companies themselves, but it doesn't really save money overall. Not really. I see you are confused. Let me explain.
Managed care saves money by reducing costs and by the indirect sleight of hand of cost shifting. This is easiest to see in the purest form of managed care, the HMO, but it exists in all forms of managed care. To see the difference, imagine you have the regular old (now almost non-existent) form of health insurance, usually referred to as indemnity insurance. You pay the insurance company a premium (or rather your employer usually does, which is another major problem, but that's another rant); the insurance company takes that money and uses it to pay for any health care claims they get from doctors and hospitals, etc., that provide care to you. If the claims exceed the premium, they lose money. If not, then they make a variable profit from you. In this model, the insurance company takes on all the risk; they don't know at the beginning whether they will make any profit, and if so, how big or small it might be. But ultimately that wasn't good enough for the insurance companies. They wanted guaranteed profit. They wanted bigger profit. So they created managed care, and especially the HMO.
Yes, I know that unless you work in the insurance or healthcare fields, you have only a rudimentary knowledge of how HMOs work. Put very simply, this is how they work. You/your employer buys an HMO policy from an insurance company. The insurance company then takes that money and takes their profit off the top. They then go to the doctors and hospitals, etc., and say 'We'll give you X dollars to take care of all this person's medical care for the year'. Sounds like a good deal, unless you happen to get really sick. Then the doctors and the hospitals lose money on taking care of you. Why? Because the amount that the insurance company gave us to care for you is less than it was in the old model, because the insurance company took its profit off the top -- and usually a bigger profit than they ever made before! In one fell swoop, the insurance company maximizes its profits and shifts all the financial risks off onto the doctors and the hospitals. And if the cost of care goes up so much that the doctors et al. won't play ball, why, they just raise your co-pay or increase the premiums; their profit is sacrosanct. When they can't maintain their profit margin because of increasing claims, they "negotiate" with the doctors et al. to reduce the amount we get paid, or they increase the premiums even more. This principle holds in PPOs and other managed care plans as well. The only difference is that the amount of guaranteed profit and risk reduction (for the insurance company) is not as great.
If I sound cynical about this, I have good reason. A few years back, the insurance company providing the health insurance for my employees decided that they needed more money to cover the increasing cost of care for their "covered lives". So they sent me a statement with a 74% increase in the premium for the next year. Seventy four percent!!!! At the same time, this same insurance company sent me a managed care contract (the contract under which I agree to see their patients and they tell me what they will pay me) including a 22% reduction in the fees they wanted to pay me for seeing their patients (which included my employees)! It's surprising, but somehow they missed increasing the patient's co-pays. So let's see, they wanted to collect more money and pay out less. Just who was saving any money here? By now this should be obvious -- the insurance company!
Remember this the next time your co-pay or insurance premium goes up. We doctors probably are not going to get one red cent more for taking care of you. We may even be getting paid less.
I hear the question coming -- how does this affect the cost of drugs? Doctors don't give us our pills, they just write prescriptions. But do you think that we doctors are the only ones that the insurance companies "negotiate" with to reduce their costs and maximize their profits? They "negotiate" with the pharmacies also, in a manner similar to how they "negotiate" with doctors. They insist on your using the mail-order pharmacies -- not because they're any cheaper, but because they own the mail-order pharmacies, and they can get your drug co-pays that way. They blackmail pharmaceutical companies to offer up incredibly steep discounts on their drugs so that they can get onto as many formularies (especially of the mail-order pharmacies) as possible. (This is the only way that the drug companies can get enough people on their drugs so that they can say their drug is the No. 1 drug used for treating XYZ, which is incredibly important to the drug companies from a marketing standpoint.) These "negotiated" prices are so low that the local pharmacies and the pharmaceutical companies have to raise the prices they charge to other customers to make up what they are losing to the managed care companies.
And that is the indirect sleight of hand of cost shifting that I feel is the greatest insult of all that managed care heaps upon the rest of us. It affects the cost of medicines and medical care alike, driving up the costs for anyone not covered by one of these managed care plans. The managed care plans then have the audacity to proclaim that their cost of care is lower than the old model, when it is obvious to anyone with eyes and a brain that this is so only because they are not counting the cost of your care (and drugs) that they have shunted off to someone else.
And that someone else is most likely some poor Joe or Jane who has either no insurance or very little, but works for a living and would never think about going onto the government healthcare system (Medicaid) and probably wouldn't qualify (because of their job) if they applied -- the least able in our society to afford this increased cost. This group until recently included about the rough one-half of Medicare recipients who did not have any type of drug coverage. It was the complaints of this group that led to the creation of Medicare Part D, the wrong solution to the wrong problem. The real solution, or at least part of the real solution, would be getting rid of managed care. But the insurance industry has our government and our politicians so hoodwinked that they could not see what the real problem was.
So managed care begat more managed care, and they called it Medicare Part D. And as more and more people get dragged into the belly of this unholy beast, it leaves fewer and fewer people out in the hot sun of ever-increasing drug prices. Eventually they won't be able to shoulder this burden any longer. And it won't be the insurance companies that suffer. It will be the pharmaceutical industry that will pay the price, or rather, not get their prices paid. When the drug companies fail, then we will all suffer, for there will be no more new wonder drugs, and a lot of the old drugs may disappear as well.
So it isn't just Medicare Part D delenda est. Managed care delenda est!!!
There was a time when I would have considered this the number one force driving up the cost of prescription drugs in this country. However, the behavior of the legal eagles over the past few years has dropped this down to a close second on my list. But it is a close second, and could overtake the lawyers at any moment, especially since the advent of Medicare Part D. (Medicare Part D delenda est!!!)
I can hear the protests from here: "But my insurance coverage saves me money -- all I pay is the copay, when I used to have to pay full price." "But I've always heard that managed care was supposed to save money, not cost more!" What most people don't understand is that managed care is a magician, and a really good one. Through sleight of hand and misdirection, the managed care industry has managed to convince almost everyone that they actually save money and reduce costs. Like most magic, however, this is only an illusion. Managed care may save you money (unless you are paying your own insurance premiums!) and it definitely saves money for the insurance companies themselves, but it doesn't really save money overall. Not really. I see you are confused. Let me explain.
Managed care saves money by reducing costs and by the indirect sleight of hand of cost shifting. This is easiest to see in the purest form of managed care, the HMO, but it exists in all forms of managed care. To see the difference, imagine you have the regular old (now almost non-existent) form of health insurance, usually referred to as indemnity insurance. You pay the insurance company a premium (or rather your employer usually does, which is another major problem, but that's another rant); the insurance company takes that money and uses it to pay for any health care claims they get from doctors and hospitals, etc., that provide care to you. If the claims exceed the premium, they lose money. If not, then they make a variable profit from you. In this model, the insurance company takes on all the risk; they don't know at the beginning whether they will make any profit, and if so, how big or small it might be. But ultimately that wasn't good enough for the insurance companies. They wanted guaranteed profit. They wanted bigger profit. So they created managed care, and especially the HMO.
Yes, I know that unless you work in the insurance or healthcare fields, you have only a rudimentary knowledge of how HMOs work. Put very simply, this is how they work. You/your employer buys an HMO policy from an insurance company. The insurance company then takes that money and takes their profit off the top. They then go to the doctors and hospitals, etc., and say 'We'll give you X dollars to take care of all this person's medical care for the year'. Sounds like a good deal, unless you happen to get really sick. Then the doctors and the hospitals lose money on taking care of you. Why? Because the amount that the insurance company gave us to care for you is less than it was in the old model, because the insurance company took its profit off the top -- and usually a bigger profit than they ever made before! In one fell swoop, the insurance company maximizes its profits and shifts all the financial risks off onto the doctors and the hospitals. And if the cost of care goes up so much that the doctors et al. won't play ball, why, they just raise your co-pay or increase the premiums; their profit is sacrosanct. When they can't maintain their profit margin because of increasing claims, they "negotiate" with the doctors et al. to reduce the amount we get paid, or they increase the premiums even more. This principle holds in PPOs and other managed care plans as well. The only difference is that the amount of guaranteed profit and risk reduction (for the insurance company) is not as great.
If I sound cynical about this, I have good reason. A few years back, the insurance company providing the health insurance for my employees decided that they needed more money to cover the increasing cost of care for their "covered lives". So they sent me a statement with a 74% increase in the premium for the next year. Seventy four percent!!!! At the same time, this same insurance company sent me a managed care contract (the contract under which I agree to see their patients and they tell me what they will pay me) including a 22% reduction in the fees they wanted to pay me for seeing their patients (which included my employees)! It's surprising, but somehow they missed increasing the patient's co-pays. So let's see, they wanted to collect more money and pay out less. Just who was saving any money here? By now this should be obvious -- the insurance company!
Remember this the next time your co-pay or insurance premium goes up. We doctors probably are not going to get one red cent more for taking care of you. We may even be getting paid less.
I hear the question coming -- how does this affect the cost of drugs? Doctors don't give us our pills, they just write prescriptions. But do you think that we doctors are the only ones that the insurance companies "negotiate" with to reduce their costs and maximize their profits? They "negotiate" with the pharmacies also, in a manner similar to how they "negotiate" with doctors. They insist on your using the mail-order pharmacies -- not because they're any cheaper, but because they own the mail-order pharmacies, and they can get your drug co-pays that way. They blackmail pharmaceutical companies to offer up incredibly steep discounts on their drugs so that they can get onto as many formularies (especially of the mail-order pharmacies) as possible. (This is the only way that the drug companies can get enough people on their drugs so that they can say their drug is the No. 1 drug used for treating XYZ, which is incredibly important to the drug companies from a marketing standpoint.) These "negotiated" prices are so low that the local pharmacies and the pharmaceutical companies have to raise the prices they charge to other customers to make up what they are losing to the managed care companies.
And that is the indirect sleight of hand of cost shifting that I feel is the greatest insult of all that managed care heaps upon the rest of us. It affects the cost of medicines and medical care alike, driving up the costs for anyone not covered by one of these managed care plans. The managed care plans then have the audacity to proclaim that their cost of care is lower than the old model, when it is obvious to anyone with eyes and a brain that this is so only because they are not counting the cost of your care (and drugs) that they have shunted off to someone else.
And that someone else is most likely some poor Joe or Jane who has either no insurance or very little, but works for a living and would never think about going onto the government healthcare system (Medicaid) and probably wouldn't qualify (because of their job) if they applied -- the least able in our society to afford this increased cost. This group until recently included about the rough one-half of Medicare recipients who did not have any type of drug coverage. It was the complaints of this group that led to the creation of Medicare Part D, the wrong solution to the wrong problem. The real solution, or at least part of the real solution, would be getting rid of managed care. But the insurance industry has our government and our politicians so hoodwinked that they could not see what the real problem was.
So managed care begat more managed care, and they called it Medicare Part D. And as more and more people get dragged into the belly of this unholy beast, it leaves fewer and fewer people out in the hot sun of ever-increasing drug prices. Eventually they won't be able to shoulder this burden any longer. And it won't be the insurance companies that suffer. It will be the pharmaceutical industry that will pay the price, or rather, not get their prices paid. When the drug companies fail, then we will all suffer, for there will be no more new wonder drugs, and a lot of the old drugs may disappear as well.
So it isn't just Medicare Part D delenda est. Managed care delenda est!!!
Sunday, June 11, 2006
Change in Identity
I can't believe it's been a month since my last posting here. My how time flies when you've been working your tail off. A primary care doctor's work is never done, and I don't mean that metaphorically. No matter how much I put in my Out box, my In box keeps getting deeper. It does not bode well for when I die.
For those few of you who have visited here before, you may notice something different. I have chosen to go anonymous. I just feel safer with these ruminations going out without my real name attached. Besides, "PostalMed" is catchier, and reflects a little more of how I really feel about some of these issues. (It's shorter to type out also when I need to do it.)
So, from this point forward, I, PostalMed, will keep up with the same raving fanaticism that I have so far demonstrated on the new and improved Rantings of a Medical Mind. More later.
For those few of you who have visited here before, you may notice something different. I have chosen to go anonymous. I just feel safer with these ruminations going out without my real name attached. Besides, "PostalMed" is catchier, and reflects a little more of how I really feel about some of these issues. (It's shorter to type out also when I need to do it.)
So, from this point forward, I, PostalMed, will keep up with the same raving fanaticism that I have so far demonstrated on the new and improved Rantings of a Medical Mind. More later.
Subscribe to:
Posts (Atom)