Endo Blog

Universal Health Care?

President Obama gave his speech last night and among other things promised a "reform" of health care.  I'm not sure if government is the answer, however, in light of this memory:

September 30, 1999

In a move that could help increase home ownership rates among minorities and low-income consumers, the Fannie Mae Corporation is easing the credit requirements on loans that it will purchase from banks and other lenders.

The action, which will begin as a pilot program involving 24 banks in 15 markets — including the New York metropolitan region — will encourage those banks to extend home mortgages to individuals whose credit is generally not good enough to qualify for conventional loans. Fannie Mae officials say they hope to make it a nationwide program by next spring.

Fannie Mae, the nation’s biggest underwriter of home mortgages, has been under increasing pressure from the Clinton Administration to expand mortgage loans among low and moderate income people and felt pressure from stock holders to maintain its phenomenal growth in profits.

”Fannie Mae has expanded home ownership for millions of families in the 1990’s by reducing down payment requirements,” said Franklin D. Raines, Fannie Mae’s chairman and chief executive officer.
”Yet there remain too many borrowers whose credit is just a notch below what our underwriting has required who have been relegated to paying significantly higher mortgage rates in the so-called subprime market.”

In moving, even tentatively, into this new area of lending, Fannie Mae is taking on significantly more risk, which may not pose any difficulties during flush economic times. But the government-subsidized corporation may run into trouble in an economic downturn, prompting a government rescue similar to that of the savings and loan industry in the 1980’s.

”From the perspective of many people, including me, this is another thrift industry growing up around us,” said Peter Wallison a resident fellow at the American Enterprise Institute. ”If they fail, the government will have to step up and bail them out the way it stepped up and bailed out the thrift industry.”

We know how well that has turned out.  If you think health care is expensive now, and I'm the first to admit it is, imagine how expensive it will be when it is free.

Should I Take a Statin?

I am continually asked by patients if they REALLY should take statins that for elevations in their LDL levels.

My answer is YES, for a couple of reasons:

Statins significantly reduce cardiovascular morbidity and mortality.

Patients. A total of 1221 patients aged 30–70 years who received a new prescription for a statin drug between 1994 and 2001, within 1 year of their first cardiovascular event (i.e., myocardial infarction, unstable angina, ischemic stroke, percutaneous transluminal coronary angioplasty [PTCA], or coronary artery bypass graft [CABG]).

Measurements and Main Results. Adherence was measured by the fill frequency (number of prescriptions filled during the observation period divided by months of observation). Patients with a fill frequency of 80% or greater were classified as adherent (661 patients); those with a fill frequency of 60% or less were classified as nonadherent (395 patients). The remaining 165 patients who had adherence rates of 61–79% were excluded from the analysis. The primary end point included a composite of myocardial infarction, unstable angina, PTCA, CABG, and death. Among 1056 patients, adherence was not associated with a reduction of the primary end point. However, patients in the adherent group were half as likely to experience a subsequent myocardial infarction as the patients in the nonadherent group (hazard ratio [HR] 0.45, 95% confidence interval [CI] 0.20–0.99, p=0.047). In patients younger than 65 years (both adherent and not), the associated reduction in myocardial infarction was even more profound (HR 0.14, 95% CI 0.04–0.46, p=0.001) and was accompanied by a trend for a lower frequency of unstable angina (HR 0.37, 95% CI 0.13–1.03, p=0.06). In patients 65 years or older (301 patients), adherence was not associated with significant changes in cardiovascular end points.

Conclusion. A detectable excess of cardiovascular morbidity appears to be associated with nonadherence to statin therapy. Our analysis suggests that many occurrences of myocardial infarction could be prevented with improvements in adherence. Larger studies are necessary to determine the association between adherence and other cardiovascular end points.

Pre-treatment with Statins Improves pneumonia outcome.

Oct. 28, 2008 -- A new study shows that people who are hospitalized while taking cholesterol-reducing medications have a higher survival rate within 90 days of discharge.

Reimar Thomsen, MD, PhD, of Aarhus University and Aalborg Hospital in Aalborg, Denmark, and colleagues, reviewed data from 29,900 adults hospitalized with pneumonia between 1997 and 2004. Of those, 1,371, or 4.6%, were taking statins at the time.

"Mortality among statin users was lower than among non-users," researchers write in their report, which appears in the Oct. 27 issue of Archives of Internal Medicine.

The death rate for statin users was 10.3% after 30 days, compared to 15.7% for non-users. And after 90 days, the death rate for statin users was 16.8%, compared to 22.4% of those not on statins.

"The differences became apparent during the first few weeks of hospitalization, a period associated with a high number of pneumonia-related deaths, and they increased only minimally between 30 and 90 days after admission, which suggests that statin use is beneficial, primarily in the early phase of infection," the authors write.

Former use of statins was not linked to decreased death rate from pneumonia.

The researchers said that other studies have indicated that statins may benefit patients with sepsis or bacteremia, or infection of the bloodstream, possibly because of the anti-clotting, anti-inflammatory, or immune-modifying properties of statins.

Pneumonia remains a major health problem. Hospitalization rates in the United States and Europe have increased 20% to 50% in the last 10 years, researchers say, and about 10% to 15% of patients die of the disease.

The report is important because it suggests another potential advantage of taking statins.

The scientists say statins change the immune response and inhibit dysfunction in blood vessels, effects that may especially benefit patients with sepsis and bacteremia, which are associated with early death from pneumonia.

"Our study adds to the accumulating evidence that statin use is associated with improved prognosis after severe infections," the authors write. "The decrease in mortality associated with statin use seems to be substantial in patients with pneumonia requiring hospital admission."

Nothing is perfect but the data strongly favor statin therapy.  Internet shibboleths to the contrary, the class of drugs seem to be both safe and effective.

Smoking and Vaccination

As I was leaving the house this morning I heard on the TV news that there was a "vaccination for smoking."  Like most reports in the media it was wrong.  Here is the actual recommendation from the Centers for Disease Control as reported in the L.A. Times:

From the Los Angeles Times

CDC panel recommends vaccination for smokers

It's the first time that demographic -- about 20% of American adults -- has been so targeted. The group is at high risk of infection from a pneumonia-causing bacterium.

By Mary Engel

October 23, 2008

A federal health panel for the first time has singled out smokers for vaccination because of their high risk of infection from a pneumonia-causing bacterium.

The federal Centers for Disease Control and Prevention already recommends the pneumococcal vaccine for children, adults over 65 and those with chronic illnesses and weakened immune systems.

The panel's new recommendation, proposed Wednesday and expected to be formally adopted by the CDC, would expand the group to smokers ages 19 to 64.

About one-fifth of U.S. adults smoke cigarettes, according to CDC spokesman Curtis Allen. Studies consistently find that smokers account for approximately half of otherwise healthy adults with invasive pneumococcal disease, Allen said.

"The risk of getting pneumococcal pneumonia among smokers is substantially greater than among nonsmokers, so it makes sense to recommend that smokers get the vaccine," said Dr. Norman H. Edelman, chief medical officer for the American Lung Assn. "But that in no way protects you from all of the terrible things that smoking will do."

The CDC committee also recommended that smokers who receive the pneumococcal vaccine be advised to stop smoking. About 50% of regular smokers will die of a smoking-related disease, usually lung cancer, emphysema, chronic bronchitis or cardiovascular disease, Edelman said.

The vaccine protects against several strains of Streptococcus pneumoniae, a group of bacteria also known as pneumococci. They live intermittently in the noses and throats of people of all ages, usually without causing harm.

But in the wrong place, they can cause middle-ear and sinus infections as well as less common but more serious infections of the lungs, central nervous system and blood.

Smoking makes it easier for the bacteria to get to the wrong place by damaging protective mucous membranes and tiny, hair-like cilia in the back of the nose and throat, said Dr. Lisa Jackson, senior investigator for the Seattle-based Group Health Center for Health Studies. Smoking also damages the ability of white blood cells to fight off infections, she said.

Not the same as reported but still important to be vaccinated for Strep. pneumoniae.

New Patients?

Sarah and I love to have new patients enter our practice.  If you are searching for first-rate care for endocrine, diabetic and metabolic disorders in the Treasure Valley, this is the place to come.  Call the office at 208-389-2213.

Hassle Factor

The Wall Street Journal had an interesting article the other day entitled Waging Health Battles by Fax written by Dr. Benjamin Brewer.  Here are the key graphs:

My patient needed his arthritis medication.

The local pharmacy couldn't get approval from his insurance company to fill my prescription for the painkiller Celebrex. They faxed me a form on which to make my case for the drug.

Completing the detailed form is my penance for trying to give a $120-per-month Celebrex prescription instead of a $4 generic. I support treating patients according to the best scientific evidence, including using standardized protocols that can improve quality and often reduce costs. But I've been this man's doctor for 11 years, and I know his medical needs. Over-the-counter acetaminophen and other arthritis products haven't helped him.

Still, his insurer thinks it knows better. And the company puts the burden on me to prove the necessity of my medication choice. The judge is someone who doesn't know my patient's history and who isn't a doctor.

The local pharmacies used to help us with these requests, but they have given up. The overhead burden was too great. There is a battle that goes on behind the walls of the family doctor's office every day. We try to get the medications and tests and referrals that our patients need while also seeing patients who require care. The insurance companies don't mind me taking heat from the patients when they don't get the medication I recommend. And they don't have to worry about the liability that I, as a doctor, face for using cheaper drugs that may put the patient at higher risk of complications.

They want me to incur the overhead and frustration that comes with trying to prove to a non-doctor that I know my patient and what I'm talking about. They want to cut costs, and they don't really care about how it affects my patients or my practice. If they make the process hard enough, they hope I'll just give up. There is even a term in the managed care literature for that kind of deterrence: the "sentinel effect."

A 2001 study showed that a doctor seeing 22 patients a day, averaged one insurance hassle lasting for every four or five patients. More than 40% of hassles were reported as interfering with quality of care, the doctor-patient relationship, or both.

I think the hassle factor has doubled in my practice since 2001. Most patients are minimally aware of the battles we fight daily on their behalf. They wonder why the office gets bogged down or why doctors or office staff don't call back. Sometimes I make it through all the hoops to get patients what they need. Sometimes I don't. I failed to convince a patient's insurance company to approve a stronger, brand-name cholesterol medication, because her triglycerides had remained uncontrolled on a generic medication for only five months, not six.

Next month I'll probably be able to get her what she needed in the first place, but my staff and I will be forced to do all the same paperwork again. Against the rising tide of paperwork, my office had to see 28 patients the day my Celebrex prescription was denied.

Dr. Brewer is spot on.  We end up fielding about 2-3 requests per day for the denial of the optimum medication for patients in favor of cheaper generic medications.  Oft times, the generics are not the therapeutic equivalents of the drug that was originally prescribed, and sometimes it happens that patients will be well controlled on their current regimen and then suddenly, coverage is denied, and they are forced to take a generic.

The worst problem is the substitution of a non-equivalent generic drug increases the patient's disease burden.
 

Thus every minute that the patient has suboptimal control of a treated parameter, the end organs affected by the lack of control are adversely affected.  Who will bear the responsibility for this?  In the end it is the patient who suffers, and the physician who bears the responsibility for rolling over and compromising his best medical judgment to save money for an insurance company. 

Drug Compliance: Barriers to Care

Here is a graph indicating what goes into patients not taking their medication as prescribed.  As expected, according to patients cost is the main driver of non-compliance but nearly equally important is failure to remember to take medication.  Difficulty in reading prescription bottle labels and inability to obtain refills are about equally important.

Let's address each of these in turn:

• Cost is not as important as you might think.  We aggressively solicit samples from pharmaceutical firms for drugs which we think will benefit you and make them available on a case by case basis as needed.  Also this office helps with filling out the forms for patient assistance programs.
• There are devices that assist with memory recall.  Almost every adult has a cell phone and all of the newer models have calendars and alarm clocks.  It is not difficult to program your phone to remind you to take your medication.
• If you can't read the label when you pick up your medication, ask the pharmacist to put your medication in a larger bottle and put a bigger label on it. 
• Refills are easy to obtain:
  • Remember to keep your appointments.  Your prescriptions are generally written to coincide with the interval between scheduled office visits.  If you don't keep your appointments, it is impossible (and illegal)to refill your drugs.
  • Do not request refills when you are out of medication.  That's too late.  You will invariably have a gap of 2-3 days before you prescription can be called in.  Plan ahead, and call for a refill when you have about a week's worth of medication.

More on contaminated food products

The Wall Street Journal today reports:

The Chinese milk-safety scandal exposes one of the pitfalls of a key strategy of the world's big multinational food companies: relying on local suppliers in emerging markets.

On Tuesday, Anglo-Dutch consumer goods company Unilever NV recalled four batches of Lipton Milk Tea in Hong Kong and Macau, which were found to contain the industrial chemical melamine, a company spokesperson said.

A day earlier, H.J. Heinz Co. said it would stop using milk from China in the baby food it sells on the mainland and in Hong Kong. Nestlé SA, the world's biggest food company by sales, said it is examining its procedures for buying milk in China, where it relies on a network of individual farmers.

I have previously posted on the problem with contaminated food products from China and how insurance companies are making money by promoting generic drugs.  Next post will link the disparate elements.

Subprime Mortgage Mess

If you think that socialized medicine is a good idea, you might want to review the governments role in creating this mess.

State Personality Traits

Today's Wall Street Journal contains an interesting article on the personality traits of residents of various states. 

Certain regional stereotypes have long since become cliches: The stressed-out New Yorker. The laid-back Californian.

But the conscientious Floridian? The neurotic Kentuckian?

You bet -- at least, according to new research on the geography of personality. Based on more than 600,000 questionnaires and published in the journal Perspectives on Psychological Science, the study maps regional clusters of personality traits, then overlays state-by-state data on crime, health and economic development in search of correlations.

View Interactive

The Geography of Personality

View an interactive map of states' personality profiles, with details on each state's rankings in all five categories.

Even after controlling for variables such as race, income and education levels, a state's dominant personality turns out to be strongly linked to certain outcomes. Amiable states, like Minnesota, tend to be lower in crime. Dutiful states -- an eclectic bunch that includes New Mexico, North Carolina and Utah -- produce a disproportionate share of mathematicians. States that rank high in openness to new ideas are quite creative, as measured by per-capita patent production. But they're also high-crime and a bit aloof. Apparently, Californians don't much like socializing, the research suggests.

As for high-anxiety states, that group includes not just Type A New York and New Jersey, but also states stressed by poverty, such as West Virginia and Mississippi. As a group, these neurotic states tend to have higher rates of heart disease and lower life expectancy.

Very interesting stuff.  Idahoans tend to be score in the mid range except on extroversion and agreeableness where it tends to rank in the mid 40s and high 30s respective.  Read the article and compare with what you find about your neighbors.

Drug Pricing

Patients often ask why a certain drug is on their insurance company's drug forumulary and another one is not.

This might be part of the reason

Rebates to drug distributors questioned

By David Lazarus / Los Angeles Times

06/02/08 20:58:08

       Some of the most influential players in our health-care system are three companies you might never have heard of.

They're called prescription benefit managers, and they oversee the prescription-drug insurance plans offered by businesses, governments and other organizations.

And, if the attorneys general of 28 states are correct, they've been pocketing money from pharmaceutical companies to steer patients into name-brand drugs.

The attorneys general announced a $9.5 million settlement last week with Express Scripts Inc., which handles the drug benefits of about 50 million workers.

The settlement with Express Scripts, the third-largest prescription benefit manager, followed a $38.5 million settlement this year with rival CVS Caremark Corp. and a $29.3 million settlement with Medco Health Solutions Inc. in 2004. The three companies collectively administer prescriptions for more than 200 million people.

Each company denied any wrongdoing.

"We have not been doing what they claim we've been doing," said Steve Littlejohn, an Express Scripts spokesman.

He said the company agreed to the settlement to put the matter behind it and avoid further legal costs.

"Now we can focus on what we do best," he said. "Our whole thrust is to work to drive down costs."

The settlements followed allegations from state officials that the companies enjoyed too-cozy relationships with drug makers that resulted in money changing hands to push favored medicines.

"What we found is that, very often, they would get rebates from the manufacturers but wouldn't pass it along to the plans," said Al Shelden, a senior official in California Attorney General Jerry Brown's office. Story continues here.

So, what the insurance companies do, through the prescription benefit managers, is to seek out the cheapest drugs (i.e., generics) and seek out rebates on non-generic drugs.  As a result, I get messages like this from insurance companies:

"Use formulary medications in place of these non-formulary medications:

Non-Formulary Medication                Consider these alternatives:

AVANDAMET                                       glyburide, glipizide, metformin

JANUVIA                                             metformin

ZETIA                                                 lovastatin, pravastatin, simvistatin, Crestor, Vytorin

AVALIDE                                             Benicar HCT, Micardis HCT, lisinopril HCT"

The problem is that the recommended drugs are either not therapeutically equivalent, or act on diabetes through methods of action that do not address insulin resistance, one of the core defects of type 2 diabetes mellitus.  Zetia is often prescribed as a stand-alone medication for patients who cannot or will not take statins, and it is obvious that this company has a contract with the manufacturers of Crestor, Vytorin, Benicat and Micardis.

It is the philosophy of this office to individualize treatment based on a patient's particular requirements.  If that happens to fit our patient's insurance company's formulary - even better.  But ultimately the decision to take the medication is not ours, nor insurance company's, but rather the patients.

Remember, there are consequences to chosing poorly.