Prescriptions, Physicians, Patients and Payers: Let the battle commence!

Last week the FDA announced that it wants to remove obstacles to America’s most commonly used drug treatments.  If the Agency gets its way, some drugs used to control chronic conditions, such as high cholesterol, diabetes and asthma may soon be available without prescription.  But in doing so, they have reopened a  big can of worms. One that brings into question the very nature of health reforms, preventative medicine and improved access to healthcare.

Here’s the proposal: The FDA would create a new class of “safe use” drugs. While consumers would not need a prescription, they would still need to get clearance from a pharmacist or from specially designed websites to purchase them.

Battle lines are being drawn! With physicians on one side, and patients, pharmacists, pharma and payers on the other.

Doctors are most definitely not thrilled by the idea. Removing the prescription requirement for an inhaler refill, for example, doctors fear they would be taken out of the loop on everyday care decisions.

Insurers, on the other hand are embracing the move. They recognize that they could save big bucks if physician visits weren’t required for run-of-the-mill complaints and ongoing medication monitoring. They might even save on the costs of the drugs themselves because, depending upon how they’re classified, most health plans don’t pay for over-the-counter treatments.

Pharmacists see it as validation of their expertise and pivotal role in primary healthcare and the pharmaceutical industry, who has repeatedly asked for permission to sell such drugs over-the-counter, must surely be cautiously optimistic.

Even normally conservative regulators are supporting the move. “Greater over-the-counter and behind-the-counter access will lower costs and make healthcare more accessible to consumers,” former FDA commissioner Scott Gottlieb said via Twitter. “It’s a good idea, long overdue.”

Even so, the FDA will have a fight on its hands as it moves to turn its proposal into reality. The American Medical Association lambasted the idea in USA Today, saying that patients need guidance from doctors. The doctors’ association also points out that giving patients more control could complicate coordinating care, such as, tracking all the drugs a patient uses to prevent interactions.

But, as The Washington Post points out, FDA sees the doctor’s visit as a hindrance to care; some patients don’t seek treatment if they have to see a physician first. “Obviously, it’s much easier for you to go to your drug store and pick up an item than it is to make an appointment, take a prescription, drop it off and get it filled,” says Nancy Chockley, president of the National Institute for Health Care Management.

About 20% of prescriptions written in the United States currently go unfilled. Removing obstacles that keep Americans from managing their own health care is, according to one patient, namely me, a good thing.

The FDA contends, and I agree, that some consumers may not even go as far as getting a prescription because of the “cost and time required to visit a health-care practitioner.  Earlier this month, I stood in line at my local pharmacy for thirty minutes to pick up a refill prescription for blood pressure meds. On reaching the end of the line I was told that there was no prescription. The pharmacist called my doctor and the lack of prescription was confirmed. I called my doctor and was told I would need to make an appointment to have the prescription renewed. I pointed out that I had done that one month earlier and that nothing had changed regarding my health. I was then informed that it was a new policy to issue prescriptions on a month-by-month basis rather than provide automatic refills. Even when I pointed out that I have a chronic condition that I’m doing my best to manage and part of that management is the medicine I have been taking for years, they wouldn’t sway. No doctors visit, no prescription.  And the kicker, I couldn’t get an appointment to see my doctor for a week…meaning, I had to go 7 days without blood pressure meds, all so my doctor could better manage my care!

Practicing medication adherence is very hard when your doctor won’t give you medication…and leaves me wondering if this policy change had more to do with revenue generation than improving chronic disease management.

My personal experience aside, at the heart of this discussion is a fundamental disagreement over what role doctors play in managing patient care. The FDA proposal views a trip to the physician as a hindrance to care, whereas doctors see that visit as crucial, especially as chronic conditions become increasingly prevalent.

The FDA proposal is still in formative stages, meaning there’s still a lot of space for this debate to evolve. Where the discussion heads on this particular issue could end up guiding health policy on what role doctors play in managing patient care – and, at what point, the patient takes charge.

I, for one, can’t wait to see how it plays out, assuming of course that I’m not dead from uncontrolled hypertension!

20/20 on the Vanishing American Hospital

Most Americans are born in hospitals. Hospitals also provide care during many other intimate and extraordinary circumstances in our lives – serious injuries, severe sickness and mental breakdown. Hospitals are also, by and large where we go to die.

As such, hospitals serve as a cornerstone of our communities and our very existence.

According to the American Hospital Association, there are 5,754 registered hospitals in the U.S. In 2011, almost 37 million people were admitted to a hospital in the U.S. – that’s more than 1:10 people.

Yet despite all this history, hospitals are in the midst of massive and disruptive change.

Even knowing this, SRxA’s Word on Health was shocked to read an article suggesting that by 2020 one in three hospitals will close or reorganize into an entirely different type of health care service provider.

Writing on KevinMD.com, a leading physician voice blog, authors David Houle and Jonathan Fleece suggest that that there are four significant forces and factors are driving this inevitable and historical shift.

First, America must bring down its crippling health care costs. The average American worker costs their employer $12,000 annually for health care benefits and this figure is increasing more than 10 percent every year. U.S. businesses cannot compete in a globally competitive market place at this level of spending. Federal and state budgets are getting crushed by the costs of health care entitlement programs, such as Medicare and Medicaid. Given this cost problem, hospitals are vulnerable as they are generally regarded as the most expensive part of the delivery system for health care in America.

Second, statistically speaking hospitals are just about the most dangerous places to be in the United States. Three times as many people die every year due to medical errors in hospitals as die on our highways — 100,000 deaths compared to 34,000.

The Journal of the American Medical Association reports that nearly 100,000 people die annually in hospitals from medical errors. Of this group, 80,000 die from hospital acquired infections, many of which can be prevented. Given the above number of admissions that means that 1 out of every 370 people admitted to a hospital dies due to medical errors.

In other words, hospitals are very dangerous places.  It would take about 200 747 airplanes to crash annually to equal 100,000 preventable deaths. Imagine the American outcry if one 747 crashed every day for 200 consecutive days in the U.S. The airlines would stand before the nation and the world in disgrace.

Currently in our non-transparent health care delivery system, Americans have no way of knowing which hospitals are the most dangerous. We simply take uninformed chances with our lives at stake.

Third, hospital customer care is abysmal. Recent studies reveal that the average wait time in American hospital emergency rooms is approximately 4 hours. Name one other business where Americans would tolerate this low level of value and service.

Fourth, health care reform will make connectivity, electronic medical records, and transparency commonplace in health care. This means that in several years, and certainly before 2020, any American considering a hospital stay will simply go on-line to compare hospitals relative to infection rates, degrees of surgical success, and many other metrics. Isn’t this what we do in America, comparison shop? Our health is our greatest and most important asset. Would we not want to compare performance relative to any health and medical care the way we compare roofers or carpet installers? Inevitably when we are able to do this, hospitals will be driven by quality, service, and cost — all of which will be necessary to compete.

So hospitals are about to enter the open competitive marketplace. And as we know there will be winners and losers.  According to Houle and Fleece a third of today’s hospitals will fall into the latter category.

Will your hospital be among them?  Let us know what you think.

Musing on MLK

Today, many Americans will be enjoying a day off work in observance of Martin Luther King.  Among these, some will be occupied in the annual tradition of trying to guess what the good Doctor would have said about current health issues if he was still alive today.

What Martin Luther King would have thought about President Obama’s health care reform requirement that all Americans buy health care insurance?

Sarah Palin wrote that, “He fought for liberty and equality because he knew they were God-given and he knew that no government should be empowered to thwart our freedom.”  The implication, being that King would have been against health care reform because it would be a blow to freedom.

Others have complained that the bills don’t go far enough towards King’s vision of equality.  They point out that millions will remain uninsured. Expensive health plans could hurt middle class workers, and the subsidies don’t go far enough towards helping poor families.  They are probably right to a certain extent – King would have pushed for a bill that did more to help poor and working families, and a bill that covered everyone.

So what do we think? Certainly Dr King would have wanted to see improved access to care for minority populations.

Health disparities are well documented in minority populations such as African Americans, Native Americans, Asian Americans, and Latinos. When compared to European Americans, minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes. Minorities also have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality than whites.  Additionally:

• African Americans have higher rates of mortality than any other racial or ethnic group for 8 of the top 10 causes of death. For example, the cancer incidence rate among African Americans is 10% higher than among European Americans.
• U.S. Latinos have higher rates of death from diabetes, liver disease, and infectious diseases than do non-Latinos.
• Adult African Americans and Latinos have approximately twice the risk as European Americans of developing diabetes.
• Native Americans suffer from higher rates of diabetes, tuberculosis, pneumonia, influenza, and alcoholism than does the rest of the U.S. population.

In some cases these inequalities are a result of income and a lack of health insurance.. Almost two-thirds of Hispanic adults aged 19 to 64 were uninsured at some point during the past year, a rate more than triple that of working-age white adults. One-third of working-age black were also uninsured or experienced a gap in coverage during the year. Compared with white women, black women are twice as likely and Hispanic women are nearly three times as likely to be uninsured.

A patients’ race also influences physician prescribing. Numerous studies have found racial differences in prescribing and treatment patterns for hypertension, hypercholesterolemia, cancer, pneumonia and diabetes.

Race has played a major role in shaping systems of medical care in the United States. The divided health system persists, in spite of federal efforts to end it. We hope that those in a position to change such inequalities take today, to reflect how such change can be implemented.

Better health care on offer but you’d better beat the crowd

Landmark health reforms will not only bring health care to the uninsured, they will bring more patients to doctors.  Lots more patients.  Forty-six million of them, all vying to find a Primary Care Physician (PCP).

In some parts of the country PCP’s are already in short supply, so the newly insured will be an extra strain on an already overstretched system.

Recently published reports predict a shortfall of roughly 40,000 PCP’s over the next decade. Not enough doctors are going into family medicine these days.  In fact, less than 30% of U.S. doctors practice primary care. The better pay, better hours and higher profile of other specialties are proving too much of a lure.

“It’s going to be harder to get appointments to see a physician” predicts Dr. Sam Benjamin, host of “Primary Care” on News/Talk 92-3 KTAR.

Provisions in the new health care bill aim to reverse this tide by offering bonus payments to those physicians prepared to expand community health services and offer them in areas where the greatest shortfalls exist.

The new law also puts emphasis on wellness care over sickness care, with policies that encourage physicians to try novel programs such as “patient-centered medical homes.”

Pilot tests of medical homes, through the American Academy of Family Physicians and Medicare, are under way around the country.  Initial results suggest they can improve quality but it’s not clear if they save money.

Only time will tell.

In the meantime, Word on Health welcomes your suggestions on how to solve the problem of too many patients and too few doctors.  Winning answers will be hand delivered to a large white building, just down the road.