For most Americans, $280,000 might represent the price of a home or perhaps their entire retirement savings. But for the 1.3 million people in this country stricken by rheumatoid arthritis (RA)that quarter million dollars could be their drug bill.
Rheumatoid arthritis is a debilitating disease that causes painful inflammation and swelling of the joints. Left untreated, it can lead to permanent disability. Thankfully medications such as Enbrel, Humira and Zeljanzcan keep patients healthy enough to stay active and keep working. Yet the price tag is quickly becoming out of reach.
One recent report from Express Scripts found that spending on drugs that treat inflammatory conditions such as arthritis rose 25 percent in the last year alone. The annual cost of treating the nation’s RA sufferers is expected to reach $9.3 billion by 2020 – a 45 percent jump from 2013.
For a 45-year-old patient recently diagnosed with RA, the lifetime cost of medication is likely to exceed $1.4 million. Even if that person has 80 percent of their costs covered through insurance, the math works out to $280,000 in copays alone.
There’s something out of kilter when families may be forced to choose between investing in a home or easing a loved one’s pain. Yet that is exactly the sort of Catch-22 some will face if we do not find a sensible way to price drugs.
When I started medical school, my South Asian immigrant parents quietly hoped I would find my way to cardiology or another glamorous specialty. Instead, I spent a decade — first as a medical student, then as an intern and resident in internal medicine — focused on advancing the right to health among poor people and others with little access to quality health care.
Through high-impact nonprofit organizations, political campaigns, and grassroots organizing in urban communities and among health professionals, I was part of an incredible community focused on making American medicine better, safer, and affordable to all.
So when it came time for me to find a “real job” after my residency, I assumed it would be in a nonprofit organization with a laser-like focus on transforming underserved health. Imagine my astonishment, then, to discover my life’s work in Iora Health — a private sector, venture-backed, for-profit primary care startup.
Profit and medicine
Critics have said that for-profit medicine makes money by finding ways to avoid caring for sick people “in their time of greatest need.” It’s also been pointed out that the Hippocratic oath doesn’t mention “money, financing, or making a profit.”
The health care mainstream is investing in a variety of mechanisms to beat back America’s health care cost and quality crisis – ACOs, medical homes, data analytics, practice transformation, technology and app integration, patient engagement and decision support – but few have borne fruit. Hidden in our system, though, are companies with unique and successful approaches. For example:
There are companies that, by collaboratively working on different parts of drug spend, consistently reduce pharmacy cost by 30-50 percent. This can result in savings of 6-12 percent of an organizational purchaser’s total health care spend, a huge amount!
Another company uses a physical therapy-based approach to manage musculoskeletal disorders, and can intervene in about 80 percent of cases. Its work with more than 30,000 patients, including in Fortune 100 firms, shows that it gets wildly better health outcomes – pain reduction, improvements in range of motion and activities of daily living – in half the recovery time and with more than a 35 percent reduction in the cost of conventional orthopedic care. Recidivism events that occur over the long term drop by 50 percent. They’re so confident of their approach that they’ll guarantee improved outcomes with a 25 percent reduction in cost.
In 1729, a bold and innovative thinker named The Very Reverend Jonathan Swift made “A Modest Proposal,” the subtitle of which was “For Preventing The Children of Poor People in Ireland From Being a Burden to Their Parents or Country, and For Making Them Beneficial to The Public.” One more thoughtful suggestion by Sir Jonathan was that Irish children, if prepared properly, made fine eating, having been assured by a “very knowing American…acquaintance” that at a year old, they are delicious, “whether stewed, roasted, baked, or boiled.”
While that suggestion never did catch on, it did represent a different insight as to a possible solution to a seemingly intractable problem, and it provoked quite a discussion. We have a new such problem, and it has to do with physicians. Today’s physicians, in their quiet moments, usually admit that their profession and they are in deep trouble. Physicians too often work too hard for too little; they spend too little time on what they consider to be the “practice” of medicine; they believe they are disrespected by hospitals and insurers; primary care docs envy specialists; specialists despise hospitals; and worst, they just flat do not like their day jobs to the point that there is rampant burnout, anger, and depression. Not quite Marcus Welby.
It starts after med school, if not during. The plight of newly “minted” physicians is dire. Unless they come from families of wealth or get some miraculous form of a free ride, they end their education and training with debt often exceeding $200,000. And given the length of time it takes for them to start making decent income, they will have lost at least 8 years of saving and investing, plus the time they need to pay that debt back. They also have to purchase exorbitantly priced malpractice insurance. Meanwhile they do things like get married, have children, and buy houses and cars, like many other professionals. Their plight is well described in a recent article which should cause even the most idealistic young man or woman to think twice before entering medicine. The burnout and depression statistics of practicing physicians today are astounding.
Charles Ornstein is an award-winning healthcare journalist who recently wrote an article in the Boston Globe about an ongoing controversy regarding a top medical publication. Yet Ornstein still wonders about the current status of medical journals:
To help answer Mr. Ornstein’s query, I have asked the editors of top medical journals to submit responses to a simple questionnaire. Here are their answers.
What would an alternative title to your journal be? The Journal of Transparent Research
What is your tag line? “Leading the charge against conflicts of interest”
What happened at your most recent editorial staff meeting? We discussed possible strategic partnerships with healthcare journalists to get Freedom-of-Information-Act orders. Independent observers should be able to get patient-level research data released from the clutches of industry and their puppet scientists and journals.Continue reading…
A reporter who covers healthcare asked me a thought provoking question recently: Is there a mandate for the adoption of telehealth? The inquiry makes sense. After all, from hospitals to health plans, employers to private practices, it is expected that the global telemedicine market will expand at an annual rate of 14.3 percent through 2020. Surely the explanation has something to do with the presence of a national requirement.
And it is the case with other health technology. As many in the industry know, the federal government mandated the adoption of electronic medical records (EMRs).The US Department of Health and Human Services spent billions to implement the Health Information Technology for Economic and Clinical Health (HITECH) Act. And providers were incentivized and penalized based not only on their adoption of electronic health records, but on the efficacy of their “meaningful use” of these new tools.
A decade ago, electronic health records were aggressively promoted for a number of reasons. Proponents claimed that they would facilitate the sharing of health information, reduce error rates in healthcare, increase healthcare efficiency, and lower costs. Enthusiasts included the technology companies, consultants, and IT specialists who stood to reap substantial financial rewards from a system-wide switch to electronic records.
Even some health professionals shared in the enthusiasm. Compared to the three ring-binders that once held the medical records of many hospitalized patients, electronic records would reduce errors attributable to poor penmanship, improve the speed with which health professionals could access information, and serve as searchable information repositories, enabling new breakthroughs through the mining of “big data.”
To promote the transition to electronic records, the federal government launched what it called its “Meaningful Use” program, a system of financial rewards and penalties intended to ensure that patients would benefit. Naturally, this raised an important question: if digitizing health records was such a good idea, why did the federal government need to impose penalties for health professionals who failed to adopt them? Perhaps electronic health records were not so self-evidently beneficial as proponents suggested.
Think about your experience in going to a standard doctor’s appointment. You fight traffic or parking hassles to get to the doctor’s office. You often wait past your appointment time in the lobby, and once you actually get into the exam room, you wait again for the doctor to actually arrive. While it may be a few minutes, it can sometimes feel excruciatingly long. The doctor arrives, and despite all the paperwork and information you shared with the receptionist or the nurse, you repeat much of this information. Once you finish your exam and discussion with the doctor – during which you sometimes take notes, sometimes not – you walk out and have that awkward moment at the front desk, wondering if you can leave freely or if you owe large sums of cash.
Sound familiar? Perhaps. Sound like many other consumer experiences these days? Not really. The simple truth is that tech-enabled consumer experiences – from booking restaurants and flights to ride requests and mobile commerce – have changed our expectations as a society. We expect
to have more control over when and where we have these experiences. We don’t wait, or if we do, we know exactly how long we will have to wait. In comparison to other consumer experiences, the doctor appointment experience — from self-diagnosis to follow-up — fails to meet today’s new standards for convenience, information and speed.
Think about the typical journey. 70 percent of people are researching symptoms and ailments online before going to the doctor, but more than half (54%) don’t write down or capture this information and other medical information before going to the doctor. We live in a world of online reservations and booking, but 88% of doctor’s appointments are still scheduled by phone, subject to wait times and potential back-and-forth. Another potential breakdown in the patient journey is communicating the purpose for the doctor visit and checking in to the appointment. Because so many are booking appointments via phone, 70 percent of people explain the purpose of their visit to the receptionist over the phone, hoping that the information is accurately captured and communicated to the doctor.
And when you arrive, the litany of forms begins.Continue reading…
I was talking with a few friends not long ago. Our conversation somehow got to the issue of authority, and what exactly respect for authority looks like. One of them, trying to make a point, turned to me and asked: “So you surely deal with people who don’t listen to what you have to say. What do you do when your patients don’t take the medications you prescribe?”
I totally wrecked his point, which made me glad because I didn’t agree with it anyhow.
Since I am in the midst of a series of posts on patient-centeredness in healthcare, I need to take a quick (1,200’ish word) detour to an important related question: what happens when the patient doesn’t cooperate? What does patient-centered care look like with non-compliant patients?
If you look up the word “compliance” in a thesaurus, the first synonym (at least in my thesaurus) is “obedience to.” This implies that non-compliant patients are, at least to some degree, equivalent to disobedient patients. This is borne out by the reaction many patients seem to expect of me when they “confess” they haven’t taken prescribed medications: they look guilty — like they are expecting to be scolded. I guess scolding is what they’ve had in the past. Certainly hearing my colleagues complain about “those non-compliant patients,” I am not shocked that they scold their patients. It’s as if the patient is not taking their medication with the express intent of irritating their doctor.
But this is a very doctor-centered view of things, not patient-centered. It assumes the doctor is the one who should be in control, and the patient’s job is to “obey” what they’ve been told. It is a “prescriptive” type of healthcare, telling people what they should do. Doctors, after all, give “orders” for things, and the Rx on our prescriptions translates to “take thou.” We are the captains of the HMS healthcare, aren’t we?
Of life’s two certainties, death and cataracts, it seems statins defer one and prompt the other, although not necessarily in the same person. If you blindly love life you may be blinded by your love for life.
In the HOPE-3 trial, ethnically diverse people without cardiovascular disease were randomized to 10 mg of rosuvastatin daily and placebo. The treatment group had fewer primary events – death from myocardial infarction (MI), non-fatal myocardial infarctions, and non-fatal stroke. For roughly ten MIs averted there were seven excess cataracts. Peter may be blinded without being saved. Paul may be saved without being blinded. And then there is Rajeev who may be blinded and saved. But the very nature of primary prevention is that you don’t know you’re Peter, Paul or Rajeev. So everyone is grateful to statins. Not even God of the Old Testament had such unconditional deference.
Once you’re taking statins there is no way to disprove that any and every breath you draw is because of statins. Statins enjoy the metaphysical carapace, the immunity from falsification, which not even God enjoys. At least you can experiment with God. Don’t pray for a week and see if you’re still alive- you know if God really cares about prayer-adherence. Even if you die at age 55 on statins, you can never disprove that you wouldn’t have died sooner if you weren’t taking statins.