Some ways to cut medical costs

The Thinker by Rodin

Are we paying too much for medical treatment? Ask a physician and they would probably tell you that you are not paying enough. Ask the rest of us and we would say, “Hell yeah!” One clue that physicians may be myopic on this is to compare how much Americans pay for health care vs. other countries. In general, Americans pay much more money for inferior outcomes.

It’s well known that a lot of the money we spend on health care is wasted on unnecessary procedures and treatments. Other spending is fraudulent. Medicare is a fee for service insurance program. All sorts of fraudulent and fly by night outfits bill Uncle Sam for bogus, superficial or overpriced treatments. These costs amount to billions, if not tens of billions a year. The problem is hardly limited to Medicare. The same is true in the private insurance market. I have a Blue Cross/Blue Shield standard option plan. My insurance company blithely went along with all sorts of medical treatment for me that turned out to be a waste of money. I had veins removed on my leg a couple of years back. Remove extra veins and the theory went the remaining veins would better take up the slack, relieving pressure on my foot and thus the numbness I was experiencing. My legs look great but the surgery had no effect on solving my problem. Indeed, it might have exacerbated it because I had to wear compression stockings for weeks after surgery. If you have a nerve impingement issue, this makes symptoms worse.

All sorts of parts of our medical system are ineffectual. We depend on physicians, but it is clear that many of them are ethically compromised. No doubt you have witnessed what I have seen many times in doctors’ offices. It’s amazing physicians can get any work done with all the drug representatives coming in and out of their office. Like Santa Claus they come loaded with Christmas presents, often including catered lunches for the doctors, but also plenty of drug samples for their pricey proprietary drugs. (I know this because I get reports from my wife, who works in a neurology practice and sees this happening regularly.) More than one physician I have encountered are on a first name basis with these drug company salesmen and women. This is not surprising since they see a whole lot more of the physician than I do.

A little legislation is in order. My physician suggested a statin for my high cholesterol. He wrote a prescription for Lipitor, which came with a $75 copay for me and costs Blue Cross hundreds of dollars for each bottle. He has done this for other drugs he has prescribed for me, even though I have repeatedly told him I prefer to start with a generic drug, and use a branded drug only if necessary. I am currently trying to get my Lipitor prescription changed to a generic. It may be that I need Lipitor, but I doubt it. I seem to have garden-variety cholesterol issues. I suspect that he prescribed Lipitor by default because of the Lipitor brochures in the examining rooms and likely on his desk. (I sometimes wonder if he is on the take, and gets a percent of any prescription he makes.) It rarely occurs to my physician to give me a generic drug. I’ll bet that your physician is the same way.

Only one physician I associate with has the presence of mind to start with a generic drug (my cardiologist). As a result my heart medicines cost about ten dollars a month instead of hundreds. No one seems empowered to tell physicians what they can and cannot prescribe. It is clear that many are in the pocket of drug companies. There needs to be a law: physicians must treat with a generic drug if available and escalate to a branded drug only for a compelling and urgent need, to be enforced by local medical boards. Moreover, the AMA should change their code of medical ethics. It should be unethical for physicians to meet with drug company representatives unless it is at neutral forums where counterpoint is possible. It should be unlawful to accept any of the bountiful gifts they receive from these drug companies either.

If we cannot enact common sense laws like these, then physicians offices should at least have a prominent policy statement in their lobbies saying how they interact with drug and similar medical companies, so patients like me can know in advance and maybe shop elsewhere. They should record and annually publish statistics on the companies that came to call, who they saw and what freebies they received from these companies. As consumers, we have a right to know if our physicians are being influenced. Right now we have to trust that the physician is looking out for our best interest.

Our primary care physicians must remain our speed dial, but it is clear to me that the primary care system is breaking down. PCPs are generalists by training. As medical knowledge has increased, it is clear that they can no longer sort it all out. What we need now are centers of expertise that can assist PCPs. A PCP would still be the one we would go to for physicals, urgent cares, cold, flus and the like. When an issue reaches a certain degree of complexity, the physician would elevate it to a center of expertise. I can use myself as an example. Both my vein surgery and tarsal tunnel surgeries were clearly a waste of time and money because they did not solve my problem. However, if it had been presented to a team of specialists (who should not be on the payroll of any health insurer), they might have had me follow a more logical course. They might have researched foot numbness like I had, figured out the tests I need, diagnosed sciatica as a likely condition and treated for that first, starting with physical therapy, then chiropractic therapy. My PCP suspected neuropathies and sent me to a neurologist. What I needed were teams of experts: a neurologist, a podiatrist, an orthopedist and likely others to put their heads together and present a step by step treatment plan, probably moving from most likely to least likely, based on my symptoms. My problem was beyond what my PCP could handle, beyond writing me referrals. Besides he had boatloads of other patients he also had to juggle.

The Affordable Care Act is moving toward elements of what I have in mind, which proposes outcome-based reimbursements rather than for a fee for service model. It all starts with a proper and intelligent assessment. The patient is the ultimate person that should approve final payment. Did the treatment solve his problem? Did the treatment persist?

A new payment model might look something like this. Unless the problem is simple enough that a PCP can handle it, the first payment would be to an outcome center for a treatment plan. It would be based on as complete a medical record as exists for the patient. The second would increase payment to 75% when the treatment plan is completed, with perhaps staggered payments if the treatment plan will require months or years. The outcome center would reimburse specialists as needed. The balance would be paid three months later when the patient certifies that the outcome was satisfactory. This would give everyone incentive to get the treatment right the first time. Moreover, physicians would begin to align themselves to meet the market for what are medical needs actually are.

There is no socialized medicine here. Those who want to see a specialist on their own would still have complete freedom to do so. The government would not dictate treatment plans or what are reasonable patient outcomes, although existing institutions like the National Institutes of Health can shepherd the creation and certification of outcome centers and best practices. Patients would get better, faster and more effective treatments. Physicians could take pride that they are doing what is best for their patient as part of a holistic approach. PCPs would find their jobs more manageable. Moreover, health care resources would align toward the efficient needs of consumers. Of course change is always scary, but changes like these are long overdue.

Chiropractors are a bit of a stretch

The Thinker by Rodin

I am not feeling too happy with physicians these days. Most specialists cannot see outside their own specialties. As for our general practitioners, they excel at treating the ordinary but often find themselves baffled by the mysterious, wherein they reach for their referral forms. This leaves us patients with more complicated medical problems often feeling desperate and depending on web sites for dubious guidance.

In 2004, I developed numbness and pain in my foot, which eventually spread to both feet. It was later followed by persistent tingling and burning on the back of my thighs when sitting. Since it started in my foot, I saw a podiatrist who stuck a needle full of steroids into my foot. When that did not work, he sent me to a neurologist and a vein specialist. The neurologist verified neuropathies. The vein specialist noticed my varicose veins and talked me into having the surface veins on my right leg removed. It was supposed to relieve the pressure on the nerves of the foot. Eventually I had tarsal tunnel surgery to treat a condition that apparently I never had. Thousands of dollars in co-pays alone were wasted. It looks like the real problems were upstream, but no one bothered to raise this is a possibility. I sure didn’t have a clue.

My primary care physician was baffled when I last saw him but when I told him I thought I had sciatica he gave me a list of referrals to more specialists. I haven’t reached the bottom of his list yet, which includes pain management specialists. I did see the orthopedist, who verified something I already knew from a previous MRI: my spine was fine. When I said I thought I had sciatica, he sent me to a chiropractor. There you can find me two to three mornings at week, generally at 7:30 AM getting traction on one of their VAX-D machines in my latest attempt to live something resembling a pain free life.

No pain, no gain. Traction is not necessarily painful, but it can be. However, it is uncomfortable. It has quickly risen on the list of things I would really prefer not to do. I would not be doing it at all if I did not feel desperate. Traction involves mounting a tight harness around my waist, lying down on the traction machine and letting the machine methodically pull me at sixty to eighty pounds, for ten cycles, while I hold on with my hands. I need to create space between my bones so things down there can move around. For a while, it made my breastbone hurt. It definitely makes my shoulder muscles hurt.

I have no idea whether this will work or not, but the chiropractor’s approach at least sounds logical. They took X-rays of my waist standing up and bending. When I bend, a space near my hipbone where the nerve to my right leg traverses is noticeably smaller than the one on the left side. The premise is that this is where my nerve impingement is occurring and is the root of my problem. Traction, ultrasound, low level electrical shocks to my lower back and right leg should allow my nerve to transmit data freely, making it go away in a couple of months. It’s like taking your foot off a hose. Or so they say.

It’s just a matter of getting a proper skeletal alignment, my chiropractors Dr. F. and Dr. R. assure me. They show me on my X-rays how one hipbone is slightly below the other. Get it and my spine in alignment so everything is aligned naturally again and I should get real relief. Alas, it’s not a simple thing to get your spine realigned. It means you have to become good friends with your chiropractors, a VAX-D machine, the youthful woman behind their counter and the women in the therapy rooms because you will be seeing all of them regularly. In fact, they may get more intimate with you than your spouse, as their soft hands slip ultrasound pads under your briefs and onto your buttocks. This part of the therapy happens after the traction when I am still trying to walk normally. I am still frequently moaning and feeling like a bat in sunshine because my head had been pushed inside the darkness of a U shaped pillow for twenty minutes. Otherwise, their hands might feel sensual. The electrical sparkly set of pads definitely gives you a tingly feeling; it needs to be “strong but comfortable” they tell me. I think I have some inkling of what it feels to be electrocuted. It would not be my preferred method of execution.

After all this therapy, you finally get to see the chiropractor. Typically, the most intimate I get with my doctor is when he puts his finger where the sun doesn’t shine during a physical. If you feel you are not getting intimate enough with your doctor, you definitely need to see your chiropractor. If they are not repeatedly violating your physical space, they are doing something wrong. Sometimes I figure I should be wrestling with them. Invariably you end up in some unnatural position with their breath close to your face, they push you sharply and some bone on your spine or hips cracks or shifts.

When I think of people with back problems, I think of obese people. Oddly, I have noticed few obese people at this chiropractic center. It’s full of very healthy looking people. Perhaps like me they ended up here in part by doing things “right”. I have been getting regular exercise for more than thirty years. I have run thousands of miles altogether, and pushed or pulled on innumerable weight machines. All of this was to stay healthy, but all that exercise turned out to have some unwelcome side effects on my body by perturbing my natural shape. It seems if you believe in exercise, you need to keep your chiropractor on your speed dial.

Yet I like my chiropractors perhaps because they are so un-physician like. So maybe this means I am starting to groove with the whole holistic medicine thing. Go see a physician and they will order tests and write prescriptions. It seems they cannot wait to get rid of you. Both my chiropractors are personable and don’t seem to be inordinately worried if you keep them a few extra minutes. They care about my problems and since you see them regularly they know you by name. Dr. R. can relate to my sciatica. He gave me his experience. “The pain was so bad I was screaming. I was living on Percocet.” Solution: months of traction and chiropractic care and it went away. “I am very hopeful for you”, he says as he had a 99.7% success rate when he worked for the military’s version of socialized medicine: Tri-care. He gave me his business card and wrote his cell phone number on it. “Call me anytime with any questions,” he says. I am not used to positive attention from doctors. Is he trying to help me, or pick me up, or both?

This is my first venture into holistic medicine. “Chiropractic first, drugs second, surgery last,” their sign says. I need to temporarily turn my spine into something more like jelly than a spine, and let things resettle into a more natural shape. To facilitate this, I must also take calcium supplements. Most importantly, I have to keep coming back, get more traction, have more sparkly things done on my spine, make more small talk with the Swedish therapist and give them a twenty-dollar co-pay. Then I stagger off to work where I periodically place ice bags under my thighs and in the small of my back to dull the chronic pain.

I obviously am not sure this chiropractor thing is going to work out, but I am hopeful. However many visits it takes, it will likely be a fraction of the cost of my two surgeries or the other specialists I saw who largely wasted my money and are causing our health insurance premiums to go through the roof. Time will tell, but I just wish I had been smart enough to start with the chiropractor. I might have removed years of pointless misery from my life.