Tuesday, July 27, 2010

The Guilty Doctor


Times are tight and we're all looking to save money, be it our own or someone else's. Many will say that when it comes to the skyrocketing costs of health care, doctors are responsible for part of the problem. We order too many tests, either to cover ourselves in the event of a malpractice suit, or because patients pressure us, or because we genuinely believe that the tests are necessary for patient care, but in many circumstances, a cheaper option is available. We order medications that are expensive when cheaper medications are available. And psychiatrists offer care-- like psychotherapy-- that could be done by clinicians who are cheaper to educate and willing to work for less money.

Here are some voices on decreasing cost: From KevinMD's post on when patients (in this case the patient is a doctor), pay cash. More on the same story directly from Jay Parkinson, here is Today I Was a Patient. The most absolutely cool thing I learned from Dr. Parkinson this morning is about a website I had never heard of before called
ZocDoc which lets people schedule on-line appointments with new physicians (including shrinks!)--like OpenTable for Docs...I asked for more info about this, but such a website fits Roy's vision of dying and going straight to heaven. And MovieDoc has strong opinions on allocating resources: we shrinks should not be letting patients ramble on about their romantic lives, why one psychiatrist can treat 1,000 patients if they stop that psychotherapy nonsense! ClinkShrink, too, has had a lot to say about allocation of services, but I'll stop now before the blog explodes.

I buy it, too. Docs should feel an obligation to care about cost-containment. In recent times, this translates very simply into the fact that I feel guilty no matter what I do. I sit with a patient and I consider trying a cheaper option for medications before I try a more expensive
one. But then I think: isn't my obligation to do my very best by this patient? Why shouldn't my patients get the latest-greatest available medication when other patients do? And what's the cut-off for how much it's worth for....relief from voices, a better mood, a good night's sleep? How do we even begin to put dollar signs on such things?

I'll give you a scenario. A patient comes to me already on an
anti-psychotic medication. He says it helps, but it's unclear why it was ever started. At some point, he stops taking it, and it becomes much more clear why he ever needed it: he becomes flagrantly psychotic and completely unable to function. I restart the medication, using the one he was on, which happens to be fairly cheap as the second generation anti-psychotics go. So all good: the med works, I know he tolerates it, and it's the cheapest of the choices, by a lot. Oh, until he gains 20 pounds. Now what? There's Abilify which is, oh, many times more expensive, but is less associated with weight gain...should I try that? I hesitate because of the cost, and then I think perhaps I should try one of the older medicines, of the Haldol generation-- much, much cheaper, but many patients hate it. As a field, we seem to agree that these first-generation anti-psychotics are not the way to start; the atypicals are the usual first-line treatment. Maybe this patient won't have side effects, maybe he'll be fine, I could "try." But isn't that making my patient into a guinea pig? If it were me, would I want to try a medication with many known side effects, when other medications are available? Nope. So I go back and forth between what is best for my patient and what makes sense for society. I share some of my thoughts with the patient, whose private health insurance pays for them, and he clearly wants what's best for him, not what saves society money.

I suppose the question presumes that I know what's best for him. And clearly, I don't. One of my big concerns is that he had this awful recurrence of a terrible illness, and each time, it takes weeks to get better,time lost from his life. There is no guarantee that
Abilify, with a more favorable side effect profile, will be equally efficacious, or that Haldol, cheaper if you will, will also work. There is the risk of relapse with any medication change and this is why some patients tolerate medications that cause weight gain or diabetes.

And then there is the "at what cost?" for that particular symptom. A patient wants a medication for sleep--
trazodone and benedryl don't work, ClinkShrink flips when anyone prescribes Seroquel for sleep ($3/pill for 25 mg per drugstore.com), benzodiezepines are contraindicated, and then there's Rozerem at $5/pill. Is a good night's sleep worth $5 night? Of whose money? And what if the patient is on generic Ambien ($1/pill or less) but wants to take Ambien CR ($4/pill) because it helps him sleep longer? And how do you feel about Provigil, which comes in at $20 a pill for the 200mg dose? Stepwise therapy, you say--- where a patient must try cheaper medications before he is allowed access to the more expensive ones? And who determines efficacy? And how do we deal with the hassles of pre-authorization? Maybe we should decide that certain medicines are so expensive that they shouldn't be offered to anyone?

23 comments:

Sunny CA said...

As a patient, I'd like to be involved in the drug selection rather than having a drug handed to me. I would want what is the "best" at balancing efficacy with side effects and let price fall where it may if I had the option. I'd also want the best psychotherapy, not the cheapest. I have one life. No need to feel guilty if you are doing the best for your patients and involving them in decision making.

Anonymous said...

What do you think of The Last Psychiatrist's proposal that each doctor is simply given a per-patient budget for meds (by the payer) and can allocate it however she and the patient think best? That is, one total amount for all meds that MD is prescribing for that patient, leaving it to the MD and patient to decide how they want to allocate that money between various meds, e.g. Abilify+Benedryl vs Haldol+Seroquel.

moviedoc said...

It's even more complicated than that, Dinah. Twice in the last few months, after discussions of risks and benefits, most likely and most serious adverse effects, what I would take if I were the patient, etc, the patient calls to tell me they can't afford the drug I prescribed. Generally I believe docs should stick to medicine and not try to get/save $$ for patients, but $4 generics are such bargain I can't help but mention them even to patients with insurance. As for preauthorization, the patient pays $50 (and must be current on their account) and signs an agreement. I don't contract with any insurers and try to keep it clear that insurance is between patient and payer. I'm not part of that deal. I can't see jacking up my low fees to patients who pay cash, to cover time I could spend helping payers keep their premiums down, and make more profit.

jessa said...

You mentioned it briefly, but I am for letting the patient help you balance known efficacy or average efficacy with cost with side effects, etc. The patient might be ill in ways that make that decision more difficult, but I would advocate letting the patient be as involved in this process as he/she is able.

This could mean asking for overall priorities like, "please always give me the cheapest, because I won't be able to take them at all otherwise."

In working with a patient, you can notice that, perhaps, certain side-effects are absolute deal-breakers. Maybe whenever a patient is nauseated by a drug, they stop taking it. In the future you can say, "this has a side-effect of nausea in a small percentage of patients, and I know that you have stopped medications before because of nausea, do you want to try this?"

You can list the drugs you are considering and the pros and cons you are weighing and have your patient help you sort them out, as he/she is going to have a better sense of which pros/cons loom largest for him/her.

Sometimes patients might not be much help in sorting this out, but they can't help if you don't ask them to.

Rach said...

does generic/vs brand name have that much of an impact on how you prescribe? has it always been that way, or just since people have become more penny pinching in the wake of the recession?

Anonymous said...

Most of the time, patients don't care what the medicine costs--they have private insurance and a set co-pay. They want the most efficacious treatment with the small risk of side effects. No one who is ill says they want to save society money even if it means they'll gain 20 pounds or get diabetes or have trouble ejaculating.

The question is a bigger issue, more of whether doctors can save money for society so that society doesn't ultimately decide to "ration" care.

I agree with you, Sunny CA that the best for the given patient is the doctor's obligation, but if I do so prescribing a medication that will run $400/month knowing that there is one out there that cost $4/month, then I'm left to feel a bit guilty.

I haven't read the Last Psychiatrist's post, but I will. Sounds horrible. So I'm to look up med prices and sit there with a calculator denying care to a patient? Would psychiatry be segregated from other specialties? I'm sorry, you're taking cancer medicines now, you've used your allotment and can't get treatment for your depression.
I know a teenager who takes a medication that costs $100,000 a year (I'm not kidding, it's for a hematologic disease). His uncle died of the same illness at the age of 9. The boy leads a normal life with this medicine. What do you say to this boy? We have a treatment that will give you a normal life, but you're not worth it?
Dinah

Anonymous said...

If the more expensive medicine works better and reults in fewer lost days for the patient, days that person could work, or days that that person is not taking up medical care, it seems to me money is saved despite the higher cost of the drug.

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Sarebear said...

Why are benzodiazepines cotraindicated? I'm guessing this goes back to the whole "Xanax Wars" post, and stuff. I know benzos aren't handed out like candy, and are often handed out reluctantly.

I'm on clonazepam for the funky stuff like sleep punching, sleep kicking, sleep yelling that I do, but the fact that it helps me sleep, especially with all the post-operative leg pain I have this year, is a big boon (especially this year, or I'd not be sleeping at all, stupid pain, after 8 months it's a bit old).

I've sort of heard there can be long-term effects if you are on it long term, and I've been on it for 3-5 years now, so I suppose I'd better be concerned about that.

Of course, punching myself in the legs right now in my sleep is the last thing I'd want to be doing, as they already hurt like bloody hell, and I used to wake up with bruises scattered on them from what I assume was my sleep punching (went away after clonazepam so must have been; I woke up to some swinging through the air pre-clonazepam so I DO know that I was punching in my sleep).

Anyway. So I'm not taking it JUST for sleep, but post-operatively this year that's been a dang good benefit, because of all the pain I'm in.

Anonymous said...

Benzos aren't contra-indicated as a sleep aide for everyone, but I meant that in this specific fictional scenario they are, say the patient is in recovery from alcohol abuse...if an occasional dose of a cheap benzo solves the problem, then there would be no reason to consider $5 pill/ rozerem and I wouldn't have a post!

sara/emerging butterfly said...

Frankly...I think that thinking about cost puts some peoples lives at risk. Top care, thorough care should ALWAYS come first. I am the victim of lazy medical practice. My beautiful son was stillborn last April, they didn't want me to cry...so they gave me morphine against my will. I'm allergic to morphine, so their plan to have an easy night for the nurses didn't go well. I died. literally. I came back. 5 weeks later in the midst of grief that was never checked in on by ANY care giver of ANY kind...because no one wants to know how a bereaved parent is REALLY doing, I suddenly began to hemorrhage. BADLY. Horror movie badly. I died. AGAIN. They discovered my son's hidden twin that had been ROTTING inside my body for FIVE weeks. Had they done a simple ultrasound before OR after the stillbirth, they would have found my second son....they would have known. But...they skipped that simple procedure and caused me to die. AGAIN. I should be grateful...I didn't die in my sleep from blood poisoning just to leave my other living children motherless. I should be grateful...but, when I wasn't "grateful" I was given a bottle of benzodiazapines to stop the crying. My mother is a benzo addict. I didn't take the pills. Instead, I got a Psychological service dog and started doing Hot Yoga. It costs more...but it's not going to harm me...it's not going to rob me of my feelings. It's not going to cause my children to have a mom high on benzos. Do my doctors care? No...they just wanted to save money...and not get sued. I'd love to tell my doctor... "Don't worry doc...I'm not going to sue you. You didn't cause my babies to die. You did cause me to die. TWICE. But...I'm back...and I don't think suing you will change the damage that was done. Don't worry doc...you can hold on to the money. You can keep every penny. I know that's really what your concerned about. Enjoy it. And just so you know....there really IS an afterlife. I've seen it. TWICE...so...you've got that to look forward to as well. Cheers."

Maggie said...

As other people have commented, this is largely something that needs to be decided on an individual basis. That doesn't necessarily mean hashing through it with every medication--a lot of people have a set of priorities that will always be a consideration when selecting a medication.

One thing that bothers me about this is the assumption that newer and more expensive means better. Sometimes that's true, sometimes it's not. And when it comes to new drugs, many times there's just not enough information about newer medications to make that determination. The fiascoes with newer drugs in recent years have proven that pretty clearly. And something isn't true just because a salesperson says it is.
The tendency to believe that more expensive means better is something that's really hard to fight, but frequently, it's nothing more than an illusion. I've encountered Etsy sellers who said that their sales went up when they increased their prices. They were selling the same items, but when their prices were lower, people assumed that they were "cheap for a reason." Up the prices, and there's an impression of quality.

In the case of benadryl vs. Seroquel for sleep, a lot of people are hesitant to take benadryl for sleep because it can cause morning drowsiness. If that's their reason, Seroquel probably isn't going to suit them any better. (And while morning drowsiness could decrease over time with Seroquel, the same could be said for benadryl.)

It seems that it's also becoming the fad in psych meds to have the drugs do more different things. Doing more isn't always better, and it also skews research results. If a drug does more things, it's more likely to cause some improvement in a larger percentage of people. But those initial studies are short-term, and if each of those people only had an imbalance of one chemical, it's likely to be more harmful than helpful to adjust others. Maybe you're more likely to see immediate results, less likely to have to try more medications before seeing some change, but adjusting chemicals that don't need adjusting is not usually going to be a positive thing. It also won't give you much information. I look at my reactions to various medications as important research--it give me me (and my psychiatrist, I hope) better insight into my brain chemistry and what exactly is wrong with it. Adjusting a multitude of different things at once doesn't give you that information, and in the case that the medication needs to be changed for some reason, it doesn't give you insight into what else is likely to work.

One other thing.. why do you leave up the spam?

Dinah said...

Rach...many of the meds don't have generics. If they do, the insurance companies/pharmacy automatically switch to them and this is okay with me. If the patient has problems with the generic (more side effects or less efficacy), then I specify name brand. There are a few meds where the name brand is more likely to be effective, in which case I want to start with name brand and maximize any shot at improvement...no interest in doing a full trial of generic then a full trial of name brand.

Sarebear, benzos are contraindicated for the fictional patient in my fictional scenario.

sara butterfly--what a tragic story.

Maggie--in the cases where a cheap alternative is a good alternative, then I don't feel guilty. It's the push--pull choices. Happily, I don't spend all day being torn.

We don't get rid of all the spam because we're lazy (and sometimes busy).

Anonymous said...

What about presenting your patient with the options? You're assuming you're the only person with knowledge here. Once you share that knowledge with your patient, then s/he gets to make the call. If s/he wants to spend 4$ rather then $1 per pill, who are you to decide that for him?

Anonymous said...

Dinah's scenario is all too common. Weight gain is practically inevitable when you have to take an antipsychotic or a mood stabilizer. But how long are you going to fret about it? Until you decide that a first-generation antipsychotic might be cheaper and more weight-neutral? Great! If the patient takes something like that for 20 years, he'll have saved copays and lbs. but will certainly have developed tardive dsykinesia.

What gets my goat the most is when I gain weight from a psych med and my primary care provider verbally assaults me with (before he even says "Hello"), "What's with the weight?!!" Everybody knows it's from the mood stabilizer. Why should I be subjected to that kind of crap, as if I've done something wrong?

Sarebear said...

OH my ....

sara/emerging butterfly . . . .

How I wish I could say ANYTHING that would be appropriate for your losses, and your experience. I am so so sorry at the horrendous, beyond negligent medical treatment you received, and wish you the best in your emotional and spiritual recovery from something I can't even begin to imagine what it must have been like. I can just offer my condolences for losing your babies, your sons, and my sorrow that you had to die, not once, but TWICE . . . . I am so sorry, and I am at the end of your story, happy that you have found things to help you, while still being sorrowful for your losses and experience.

Maggie said...

But Dinah, with older, cheaper drugs, you know all of the side effects. Almost all of the expensive drugs are newer. If a drug hasn't been out for very long, nobody knows what the long term side effects are going to be, because nobody has been on it for that long. So you take a drug that alters the same chemicals, as well as others, and since there haven't been any long term studies, it can be claimed that there aren't long-term side effects. How probable is it that those side effects don't exist at all, versus the probability that they'll become apparent once the drug has been used long-term? And how likely is it that a drug that alters multiple brain chemicals will have fewer side effects than one that alters just one? Logic dictates that the more different things you change, the more effects there will be.
I have trouble imagining the possibility that if drug A alters chemical A and has A side effects, and drug B alters chemical B and has B side effects, that drug C that alters chemicals A and B would have fewer side effects than either A or B. And if some percentage of people have an imbalanced chemical A, and some percentage of people have an imbalanced chemical B, you'll probably see some improvement in those people from taking drug C. So studies would show a higher "success" rate of drug C than of drugs A or B. Would that make drug C superior to drugs A and B? I'd have to reason that drug C would only be appropriate in the overlap between those groups.
But if drugs A and B have both been out for 20 years, and there is no denying their side effects, while drug C has only been out for a year, it'd be pretty easy for somebody selling drug C to convince an awful lot of people that it really was better.

EastCoaster said...

But the weight gain is not a joke.

I work for a human services agency which helps people with serious and persistent mental illnesses--both those in group homes and those living independently.

Our medical director believes very strongly that we should be taking weight gain as a side effect very seriously. In a group home with 10 people, probably 3 have diabetes and 5 have heart disease.

The newer (90's atypicals) may be better, but the difference in life expectancy between the general population and those with major mental illness has gone up to 25 years from about 10-15.

She is a psychiatrist, but she believes that the psychiatrists are not taking the medical consequences of their prescribing patterns seriously enough.

And some of these clients don't have a choice.

Maggie said...

I agree with you very much, EastCoaster. Have there been studies on life expectancy differences that have excluded suicides? That always seems to me a factor that interferes with accurate statistical comparisons.

I have to admit that I didn't know about the increase in the life expectancy differences between "normal" people and those with mental illnesses. It's something I've wondered about, but doubted the objectivity of studies in comparing true cohort groups. Statistics can be tricky; somebody who wants a particular result can usually find a way of getting that result. It seems to me unlikely that medications as powerful as many of those that are used could possibly not have long term effects, which is why I hold so firmly to the idea that medications shouldn't alter any more chemicals than necessary.

I don't think anybody is taking the long-term effects of these drugs seriously enough; it's too easy to pretend that there aren't long-term effects just because a drug hasn't been around long enough to have seen those effects.

EastCoaster said...

Maggie,

Those studies ALL exclude suicide.

Maggie said...

EastCoaster, are you citing specific studies, or news articles? It looks like there have been a few mainstream news articles on the topic of life expectancy in mental illness, but they don't really go into study methodology.
This study at psychiatryonline.org is a bit older, but does include suicide, and also notes that the incidence of undetermined cause of death is much higher in the mentally ill population.
Most studies also note the higher rates of tobacco use and substance abuse among mentally ill populations, which also skews results. But I don't think that a study COULD exclude those populations because it would be overlooking too large a portion of the mentally ill population. I think that before the psychiatric community in general could possibly start taking responsibility for long-term side effects, there would have to be proof that these things are side effects rather than consequences of other factors.
But how can anybody provide that proof when the drugs being pushed are always the new ones? As soon as proof came out, drug companies would have even more leverage to sell their next brand-new never-been-tested-for-longer-than-a-few-weeks pill.
Until psychiatric diagnosis can be made scientifically, I'm going to have to assume that higher efficacy rates mean that a drug is more dangerous. "Working" on a larger portion of a population that's determined by symptom rather than cause can probably be translated to "less targeted." Especially when they start pushing the same drug for multiple disorders.

EastCoaster said...

No, I'm not citing specific studies and am being lazy.

A lot of the problem is not caused by the meds. Something like 65% of people with schizophrenia smoke, which is bad on so many levels.

The point is that suicide is not the major cause of reduced life expectancy in people with major mental illness, serious and persistent, whatever you want to call it.

SAHMSA is hoping to regain 10 years of life expectancy in the next 10 years.

snoring solutions said...

I don't contract with any insurers and try to keep it clear that insurance is between patient and payer.
Sometimes patients might not be much help in sorting this out, but they can't help if you don't ask them to.Thanks for your valuable contribution!