Thursday, October 25, 2007

Google, Nielsen, Health Care Limits, and Primary Care

Yesterday’s New York Times reported on a partnership between Google and the Nielsen company. The article made me worry even more than usual about the harried life of our primary care physicians.

With Google’s data mining capacities and Nielsen’s detailed tracking of television viewing, advertisers will soon have vastly more precise information about which viewers see which advertisements. Not too far down the road we can anticipate marketing targeted to individuals in accord with their television viewing and Internet use patterns. Direct to consumer drug advertising is already effective in driving demand for branded products and will become more so.

Think of what this means for the primary care physician (PCP). More and more patients will come to appointments with specific drug requests. When advertising has alerted the patient to a uniquely effective treatment, health is advanced and free speech serves its purpose.

But what about costlier, branded, me-too medications? For patients who will be paying for the medication themselves the PCP can be an adviser – “it’s your money, but I don’t think it is worth it for you.” For patients with tiered drug insurance the PCP can similarly advise as to whether the higher copay purchases comparable benefit.

Patients, however, will increasingly ask their PCPs to appeal on their behalf. Appeals are time consuming. When the appeal is clearly justified physicians grit their teeth and do what is necessary. But when it is for an advertising-driven me-too product physicians have to choose between spending uncompensated time trying to convince the patient that the drug is not called for or spending uncompensated time on an appeal they do not believe in.

Our health system has largely stopped putting primary care physicians at direct financial risk for the cost of the medications they prescribe, but PCPs are often subject to other forms of pressure about their prescribing practices. Placing PCPs between the Scylla of evidence based prescribing and the Charybdis of ever increasing advertising-fueled patient demands will only add to the overburdened state we have already put them in.

Good medical ethics requires a robust system for making appeals about insurance limits. But a viable health care system requires a robust primary care sector. If we continue to drown our PCPs the sector will vanish.

It is possible to create processes that protect patient interests in access to medications that are “needed” rather than simply “desired” and at the same time protect physicians from unreasonable “hassle.” Kaiser Permanente’s approach to managing Selective Serotonin Reuptake Inhibitors (Prozac and its cousins) shows us how to do this. Our discombobulated health system needs to learn from exemplary practices like the one Kaiser Permanente offers.


Anonymous said...

I don't think it's a coincidence that you see the highest occurrence of a single manufacturer holding patents on both the brand and leading market generic equivalent in this class of medication. Eli Lilly (Prozac/fluoxetine), Forest Laboratories - formerly Parke-Davis (Celexa/Citalopram) and (in the SNRI field) Wyeth (Effexor/venlafaxine) would all, most likely, be willing to cooperate with such an initiative when there is a greater chance that the more cost effective option is another of their products. I would be interested to see how many patients in this program are moved from Zoloft (sertraline) to another medication altogether, where Pfizer holds the primary patent on Zoloft, and Teva is the main generic distributor.

Jim Sabin said...

Hi Ian --

Thanks for this very informed comment. As I see it, if the brand manufacturer competes in the generic market on fair terms, the increased competition is a good thing for patients and the economy. My fear is that the large companies will find ways to block generic competitors in an anti-competitive manner.

Anonymous said...

Interesting issue, and great blog, by the way.

Anonymous said...

So, You Want To Be A Doctor……

Lately in the media, others have said and appear to express concern about the apparent shortage of primary care doctors in particular. Typically, the main reason believed and speculated by others for this decline of this health care profession specialty that historically has been the apex of our health care system is lack of pay of this specialty when compared with other specialties chosen by potential physicians while in training, as the annual salary of a PCP is around 130 thousand a year on average, others have concluded may be the national average and factors in payers both of a private and public nature.
Yet considering the additional attention of shortages of students in some medical schools as well, as conceived by others, one could posit hat this professional vocation that has been one viewed in the not so distant past in the U.S. as one with great esteem and respect may not be desired as a vocation by many, that requires commitment and dedication, as reflected in their training regimen in the U.S. that consumes about a third of thier lifespan. Such reasons for this paradigm shift may include:
Primary Care Doctors perhaps more than other physician specialties seem to be choosing to practice medicine under the direction and financial security of one of the many and newly created health care systems These regional and nationally created systems are typically composed of numerous hospitals and clinics under combined ownership- frequently of a private nature that is not dependent upon their beliefs as it is perhaps on their profit motives and intentions. Yet their approach and etiology of their views regarding the restoration of the health of others are usually similar with such mergers of multiple medical facilities, which are presently preferred to save costs, it has been said, and therefore these systems have not been protested by a largely uninformed public.
Conversely and in addition, this system of increasing popularity is not necessarily a desired method to practice medicine as a primary care physician, often stated by them as members of their employer that has the power to limit and dictate how they practice medicine. This is because, among other reasons, such doctors have largely unexpected and unanticipated limitations regarding their patients’ heath provided by them. This is further aggravated by possible and unreasonable expectations of their employer, such as mandating that doctors they employ are required to see as many patients as theycan in a day, and there have been cases of physicians being fired by a health care system- along with financial rewards for seeing more patients a day than what is determined as average visits by others. Such requirements likely and potentially affect or alter the clinical judgment determined by physicians employed in what may be viewed as authoritarian employers, which would limit the medical care they provide to their patients, as well as the quality of this care. Also, such health care systems may have their own managed health care system that may be determined by factors not in the best interest of the patients of doctors employed by the health care system.
The primary etiology and stimulus for a doctor to practice medicine in this way is due to their frequent inability to provide and employ ancillary staff, combined with the increasing premiums for their mandatory malpractice insurance, which may make doctors financially unable to work independently.
Malpractice laws and premiums, which is determined in large part on a state level, are an issue with those required to have this adverse aspect of their professions. Also, these premiums become more expensive for doctors, depending on the perceived risk of their chosen specialty. For example, the premiums of an OB/GYN doctor are usually higher than one of a specialty viewed less risky for lawsuits, such as Dermatology, perhaps. Plantiffs win about 25 percent of the time on average a half a million dollars. 95 percent of these cases are settled out of court.
In addition, the issue of medical malpractice is also frequently a catalyst for a doctor to practice what has been called defensive medicine, which basically means that the health care provider is prohibited from relying upon their subjective factors in their assessment of their patients, which in itself raises the question of what the point was of all of their training in the first place. Because if a doctor practices medicine in such a way, it typically involves what may be considered as unnecessary diagnostic testing for their patients to rule out what may be unlikely disease states of their patients’ medical conditions. This waste of medical resources is further validated by the legality reflected in the tone of the notes a doctor usually annotates or dictates with their patients.
Such restrictions and limitations imposed on today’s primary health care provider are usually not fully illustrated during their training for this profession, which is one that has been viewed as one that is quite noble and of great responsibility on a societal level. It seems that this perception and vocation that now is greatly misperceived due possibly to being deformed by others who may have profit as their motive for the health care they may dictate to doctors they may employ in some way, which often and likely is in conflict with their motives as doctors and how they wish to deliver needed health care to others. This may be why this medical profession may no longer be viewed as distinct from other vocations, in large part, as it seems that presently the profession of a doctor has been reduced to one dependent on the financial stability and growth of its employer, which may alter how the doctors perceive what is expected of them as well, which may affect the importance of how they view their profession, as it has been said that overall, doctors are somewhat understandably more cynical and demoralized, which may be replacing the pride they historically have viewed their callings as doctors, as well as the perceptions of patients in the U.S. Health Care System.
Further complicating and vexing to these restrictions is the usual financial state of the individual physician, as theynormally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training is completed, it has been estimated, along with this debt amount presently is about 5 times higher than it was only a few decades ago.
Conversely, there are some who believe that doctors in the U.S. are over-paid and are compared with some corporate monster, who behaves based upon the premise of greed. In spite of how they are judged, physicians are likely not absent of financial concerns- which may be of more of an issue than many other professions, comparatively speaking, in addition of taking on more responsibility that is of greater importance compared with other vocations. Such realistic variables should be factored in when one chooses to judge the profession of a physician. On the other hand, no physician should view their jobs as no different from any other venture capitalist when rationalizing their income and motives related to this exceptional vocation as a physician, as others are more dependent on their judgment.

It has been determined by others, and suggested often and lately, that many of today’s physicians practicing medicine in the United State do not recommend or speak favorably of their professions compared with their typical views of their profession in the not so distant past. While this self-perception physicians may have of a negative nature may be somewhat understandable it is also and potentially unfortunate for the health of the public in the future, and the nature normally associated with the medical profession which could deter ideal medical care for others
There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state perceived by themselves as well as others of their profession as medical doctors.
Then again, not all doctors are deities. Like others, some are greedy and corrupt, which complicates others in this profession in relation to how their vocation is viewed by others and based on limited judgment and analysis. Yet citizens overall should determine what sort of health care they desire, and it seems that often they fail to voice this right as a citizen.
For perhaps Primary Care Physicians in particular, the medical profession and those who provide medical care clearly needed by others to some degree appears to be absent as a desired path of today’s careerist. The authentic reasons for what many believe to be a negative perception of possibly the entire health care system may never be known, yet many would agree that most U.S. citizens are understandably concerned with the state of this system of great importance to society. Yet need to be active more in assuring this necessity is more aseptic.
“In nothing do men more nearly approach the Gods then in giving health to men.” --- Cicero
Dan Abshear
Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.