Friday, December 31, 2021

Why do we have to wait so long to see the doctor? It's all about the money...

I have seen a number of articles describing the difficulty of getting doctor’s appointments in the era of COVID-19. In many parts of the country it was difficult to get a quick appointment even before the pandemic, but it has become much worse. I hear from friends in a several different cities that they cannot get into their doctors offices for weeks or, commonly, months. This is not OK for routine care; it is certainly not ok when something urgent, or relatively urgent, or even a little bit “needs to happen before I get really sick” is going on. A recent article in the Wall Street Journal by Devorah Goldman (‘The doctor’s office becomes an assembly line’, December 30, 2021) describes a woman who came to her father’s Brooklyn office from New Jersey because she couldn’t get an appointment for 8 months!

There are Emergency Rooms, of course, but waiting (frequently for hours!) in them increases your risk of acquiring COVID infection. And, as in “regular” times, they should be for emergencies, not for care for chronic diseases or minor acute disease. Of course, if you cannot get regular care for your chronic disease, it can become an emergency. And, as I have written before (Emergency services, COVID, and the health system: Your life could well be at risk, Jan 19, 2021), when you have an emergency, like a ruptured appendix, waiting in an ER for hours is also very dangerous, and the more “non-emergent” people waiting the more likely this is to happen. There are Urgent Care Clinics, but these have their own issues: they can only take care of a limited (and variable by location) menu of problems, most of which are those your mother used to take care of, and they may not take your insurance (if you have it). Also the prices and profit margins are very high.

So why are the waits so long, and what can be done about it? Goldman’s emphasis is the takeover of physician private practices by hospital systems and large groups; she notes that, according to the AMA, 75% of physicians owned their own practices in 1983, but by 2018 it was 46%. This is part of the problem; even if an individual physician is compassionate and caring, the big corporation they work for probably is not. Another part is the maldistribution of physician specialists. Studies of efficient and effective health care systems indicate that 40-50%+ of physicians should be in primary care, seeing people for most problems, providing continuity of care for a patient panel, and diagnosing “undifferentiated patients” (those who do not have a specific diagnosis) and caring for them or appropriately referring them. In the US, however, it is less than 30% and dropping. Quite reasonably, subspecialists want to see people with the problems that they know how to take care of; this works well when they are referred by family physicians and other primary care clinicians, and much less well when people have to self-refer, essentially having to diagnose themselves. Such direct self-referral also backs up the subspecialist practices with patients whose problems could have been well taken care of by a primary care clinician (not everyone with a heart needs a cardiologist!) making it more difficult for those with complicated or rarer conditions that need the subspecialist’s care to get in. Medicare’s reimbursement method figures prominently in Goldman’s article; she identifies ways that it tends to give preference (i.e., pays more) to large, and especially hospital-owned, medical groups. And, of course, since COVID the demand for care has gone up, and the number of clinicians available (because of sickness and overwork) has gone down.

Many other articles claim to provide the reasons for this problem, and some even have proposed solutions, but most of them examine only one aspect of it. I am reminded of the old Indian story about the blind men and the elephant, each touching a different part of the beast and thus presuming, based on contact with the trunk, the tail, or a leg, that they knew what the whole elephant looked like. Often this is influenced by the agenda of the writer and whether (like, e.g., Goldman) they get their information mainly from groups like the AMA (“oh, for the days of physician-owned private practice!”), hospital associations (“consolidation is good!”), government agencies (“reimbursement policy is governed by competing needs”), or academics, think tanks, or nonprofits like the Commonwealth Fund, Kaiser Family Foundation, and Pew Trusts, often with their own biases. To me, it is clear what the whole elephant looks like, what is the common factor in this equation, what can be seen behind all of the decisions that have led us to where we are (and continue to make it worse) and, by implication, could show us the way out: Money. Corporate profit.

We live in a profit-driven capitalist society. More than that, we have moved well beyond simple “Adam Smithian” capitalism to what Noam Chomsky identifies as “gangster capitalism”. In this stage, merely making money is not sufficient – the only goal becomes to make ever more money, by any and every means possible, no matter who, or what is destroyed. This includes people, animals, plants and the earth itself -- it hurts, screws, destroys, even though neither those who control it nor their descendants could ever spend it all. Fewer and fewer people control more and more and it would be naïvete to assume this is not the case in health care.

Virtually all the systemic bad things (as opposed to the much less common individual error) in healthcare derive from corporate owners’ efforts to make more money, and to game the system to maximize profit. While huge practice groups owned by hospitals or investors could operate more efficiently to improve both the quality of and access to care for patients, they don’t since they are interested in squeezing every dollar of profit. Conversely, small physician-owned practices couid do better than they do, but often, in pursuit of income, do not care for significant portions (poor, uninsured, badly insured) of the population. Explicitly for-profit (as opposed to ostensibly non-profit, but still fixated on making as much as possible) healthcare entities, whether large hospitals and hospital systems or more ‘niche’ services like dialysis, physical therapy, and long-term care, are the worst. There is certainly plenty of blame to go around – healthcare systems blame insurance companies for not paying them enough and insurance companies blame healthcare systems for demanding too much, but both are seeking to earn money for themselves, not to ensure all people get the highest quality health care.

Pharmaceutical companies are notoriously rapacious. For example, see Aduhelm® (FDA approves Alzheimer's drug against the recommendation of its scientific panel. Be very concerned, June 21, 2021); every (60 million!) Medicare recipient’s Part B payments will now rise $11/month so some Alzheimer’s patients can receive this drug that, though probably ineffective, costs a huge amount (now, graciously, reduced to only $28,200/year!). It was approved by the FDA over the recommendation of its scientific advisory panel in a move completely reminiscent of the fraudulent labeling of Oxy-Contin® described in the film “Dopesick”, which I recently discussed ("Dopesick": The story of the marketing of killer opioids will really make you sick. Don't trust any of them!, Dec 7, 2021).

I have often advocated for a single-payer health insurance system, such as Medicare for All. The advantage of this would be that 1) everyone in the US is covered, and 2) everyone in the US has the SAME coverage, The second is not a minor point, as it means that the educated and powerful will make sure it works, also helping the disenfranchised and disempowered. A universal health insurance system (or something comparably effective) is necessary, but not sufficient. Medicate for All needs to be an improved and expanded Medicare, as described in the bills introduced by Sen. Bernie Sanders, Rep. Pramila Jayapal and others.(See this good analysis by Sen. Sanders on the “Vulgarity” of the US health system.) It must be expanded to cover not only everyone but everything (mental health, dental, vision, hearing, long-term care) and improved to cover them completely without co-pays, co-insurance, deductibles. This will eliminate the flaws Goldman describes in Medicare payments.

Since we already spend 2-3x as much per capita on health care as any other wealthy country, including premiums, deductibles, co-pays, government benefits, and the profits and administrative costs sucked out of the “healthcare” pool by insurers and providers, we don’t even need to tax the richest a lot more to pay for it. We just need to spend it on actually providing healthcare! Not that we shouldn’t make the billionaires and corporations pay at least their fair share of taxes; we can use that money to providea adequate housing, food and education to all our people – really, the biggest factors in health.

Don’t get distracted by the circuses and diversions created by those with a profit-motivated dog in the fight. Profit has little place in healthcare. Obscene profit has none.

Tuesday, December 7, 2021

"Dopesick": The story of the marketing of killer opioids will really make you sick. Don't trust any of them!

I have recently been watching “Dopesick”, the Hulu/Disney+ quasi-documentary drama about how the Sackler family-owned Purdue Pharma developed and marketed Oxy-Contin®, and about the efforts of some brave federal prosecutors and DEA and DOJ agents brought them (somewhat) down. Based on the book by Beth Macy, it is a good series, with terrific performances and many sympathetic characters (not the Sacklers, though, none of them) and although I am sure that there fictional elements involving the personalities portrayed, it is essentially factual. It is also infuriating, and nauseating.

If you haven’t watched it, you probably should, but you probably already know the main theme, so what I write won’t be spoilers. It is still worth watching, to understand the extent of the evil, and the way in which the medical profession and federal agencies were “played” successfully as thousands of Americans became addicted and died. A few of the outrages include that when Purdue developed Oxy-Contin, using a delivery scheme developed for MS-Contin®, which was going off patent, they claimed its slow-release delivery mechanism made it essentially non-addictive (less than 1%), and got a first-ever special label for a Class II narcotic from the FDA saying it was less addictive (it was not). They did a very effective job not only marketing (detailing) to physicians with this lie, but created new diseases (conditions) that justified its use. This was also taken from a previous drug and scam, when Arthur Sackler invented the condition “psychic tension” to market Valium®. When, predictably, people first got pain relief, then developed tolerance they invented the condition of “breakthrough pain” which required a higher dose. Then folks got tolerant of that. And when they stopped, they went through awful withdrawal. This is what happens with opiates and opioids. And yet Purdue was able to convince doctors to continue to prescribe it – and prescribe it in increasing amounts.

This was part of a movement going on in the 1990s to address the issue of people not always receiving adequate pain relief. The pain of diseases, such as cancer, that occurs as people approach death, got conflated with the moderate chronic pain that millions have from work related injuries (the focus of the drama is on a mining area of Virginia) and from conditions such as osteoarthritis. These are real problems, but the answer was presented as opioids, and ever increasing doses of them. What was not well-known at the time is that, to a large degree, this “movement” was in fact a campaign funded by Purdue. They funded – and thus heavily influenced -- most of the medical Pain Management groups, as well as the campaign to label pain the “fifth vital sign” (after temperature, pulse, respiration, and blood pressure), an idea they invented. It was a drumbeat that was ubiquitous. The pain movement was essentially, a marketing campaign for a lethal drug. It was successful, in both ways. It made the company, and the family, a lot of money, and it addicted and killed a lot of people.

The Sacklers didn’t seem like the meanest of billionaire families (of course, this is a low bar). They were philanthropists, who gave a lot of money to the arts, and to Israel and Jewish organizations, and health care, and even funded a medical school, the Sackler School of Medicine, part of Tel Aviv University and located in Israel but chartered in NY state. It still exists. They were, however, and remain, avaricious and essentially amoral, continuing to refuse to recognize their evil-doing, while remaining #30 on the Forbes wealthiest list, and managing to retain and hide nearly $11B in their own private money despite the $8.3B settlement. And thousands of people are dead and addicted. The people most affected were poor and working class people, those who work with their bodies and most often experience chronic pain, such as those the series focuses on, miners.

But the story cannot end with the Sacklers, Purdue, and Oxy-Contin. While some of their tactics were particularly creative and perfidious, the effort to market drugs with high profit margins (even when they are often less effective and more dangerous than other existing drugs) is the Holy Grail of the pharmaceutical industry. What Purdue did was possibly more insidious – and effective -- but it was typical in being multi-pronged, targeting consumers, physicians and the federal government.

The government was targeted by lying to them, and knowing they were unlikely to be caught as the FDA’s staff (as the staffs of almost all regulatory agencies) had been decimated by cuts beginning with the Reagan administration, aimed at allowing corporations to have freer rein – to lie, cheat, and profit at the public’s expense in $$ and, in this as in many cases, their health. It was a flagrant example of the corruption of the ubiquitous “revolving door”, where those who are tasked with regulating industries then leave government service and get high-paying jobs in those same industries. Indeed, this is what happened with the FDA official who approved the novel labeling of Oxy-Contin -- he went to work for a big salary at Purdue -- and it happens every day in every field, not just pharmaceuticals. It is, pure and simple, graft.

Doctors were targeted through pharmaceutical sales representatives (“detail” people) who provide them with incomplete and often inaccurate information (e.g., that Oxy-Contin was only 1% addictive), and take them to expensive dinners and even vacation retreats under the guise of medical lectures. And the company, of course, encouraged their own reps to lie with enticements such as vacations. And the public? They present tantalizing, incomplete, and dangerous information through ads, especially on TV.

I have written about TV direct-to-consumer advertising, (e.g, DTC Advertising on TV illustrates the corruption and inequity of the US medical care system, Mar 6, 2021) and think it is pretty much all bad. I think that the marketing of drugs to doctors, to get them to prescribe expensive drugs, is mostly all bad. I have thought that, by the way, pretty much since at least medical school. I didn’t meet with drug reps, was very skeptical of information they provided (which I saw in journal ads and heard from colleagues) and assumed any positive claim was very likely incomplete or untrue. During my career, any number of highly-touted drugs were pulled from the market after causing major morbidity and mortality that was either not predicted in the pre-approval studies or suppressed by the companies. As a teacher of medicine, I sponsored “counter-detailing” to point out the flaws of the pharmaceutical company claims. I was aghast when residents would come back from conferences supposedly sponsored by professional associations but funded by drug companies that recommended the substitution of new expensive drugs for old standards that worked at least as well. This has been recently documented for diabetes (another field in which much of the funding has come from the drug makers) in an article from Reuters, ‘Drugmakers Pushed Aggressive Diabetes Therapy. Patients Paid the Price’, featured by Medscape Nov 5, 2021.

And yet, even so, I was not immune to the campaigns that Purdue funded, especially the idea that pain was being undertreated, although I remained unconvinced that it was the “fifth vital sign”. To be sure, I was much more skeptical than many of my colleagues, and was careful to distinguish between relieving the pain of a terminal cancer patient and addicting a person with chronic moderate pain. But it was a very well-done campaign, and I knew that at least sometimes we were undertreating pain. At Cook County Hospital, where I worked, we saw many patients with sickle-cell pain crises, treated with opiates and opioids, and frequently becoming addicted (interestingly, the chief of pediatric hematology only used aspirin and hydration, but as soon as those children became adults they began to receive narcotics).

We must remember that it was and is not just Purdue. Don’t trust what any drug company (or maybe any company) says in TV ads. Don’t trust what the pharma reps say. And sadly we cannot always trust recommendations of professional organizations when they are getting money from drug companies. This is real conflict of interest, and makes our professional organizations suspect.

It is all about making the most possible money by any means necessary, no matter who gets hurt, what Noam Chomsky calls “gangster capitalism”. You’re better off trusting real gangsters who literally put a gun to your head. At least you know where you stand.

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