Wellness Invitation

Threescore and ten has arrived.  Not been there long enough to make any judgment of whether granted the vigor to make it to fourscore.  I wonder why the English translations of the Psalms always present in this way as the Hebrew just uses 70 and 80, but there must have been some type of reverence for advancing age.  Without reverence but with steady payroll deductions, Medicare has also arrived, mostly a pretty good plan with the supplement that I have.  Realities brought me to a new primary physician and I periodically touch base with a cardiologist, soon to be declared well enough to latch on to her NP.  I think I am well enough.  Symptoms are some blend of nudgy and insidious.

Automation being what it is, I received a message to take advantage of a Wellness Assessment, paid by Medicare at no cost to me.  While I recently had a semi-annual visit with my primary doctor, my focus deviated a bit from the expected purpose of the follow-up.  When I telephoned the office concerning whether I needed to see the doctor or her surrogate again, I was told that Medicare's Wellness program differed from their usual office visits.  Not knowing what it entailed, I made the appointment for about a month hence, then proceeded to the www to determine what might be in store.  Apparently the purpose is to look at risks and to some extent resilience.  I wish I felt better but don't feel badly.  Cognition checked as part of a research protocol, so I did pretty well.  Mood could be better.  And one day I will stumble over clutter at home and fracture something or fall down the stairs.  I don't have a lot of medicines or a lot of providers.  I can be an ROS + if the detail is sufficient, though.  I don't engage in hazardous activities.  Vision good.  Hearing good.  Weight seems to be declining, I assume in response to some dietary changes of a few months back.  I'm mostly well.  See if she concurs.

My receipt from a very fine local pharmacy listed no copay for me.  It included the retail prices that would have been charged for a cash transaction for each three month supply.  Citalopram $14, Lisinopril $14, Rosuvastatin $805.  My annual Medicare prescription coverage premium is only about $200 and they list Rosuvastatin as a Tier 1 which has no copay.  That means the insurer will not get my price of $805 for this.  It comes in a pre-packaged bottle of 90-pills made in India.  It has been past its patent expiration for a few years.  When Good Rx prices are surveyed, the prices range from about $15 to $173 which is what my previous mail-order pharmacy charged me as my co-pay, with a more expensive variant of the same insurance carrier classifying it as a Tier 2.  That is why they are my previous pharmacy and I have a new plastic insurance card with the lower premium plan.  Good Rx also lists each pharmacy's retail price with a variation from $140 to $765, all at pharmacies or pharmacy divisions that are household names and presumably commercial competitors.  And none are $14 like my other generic pills. Something is very amiss.

When I go to buy an artistic Jerry Garcia tie, which either goes with everything or with nothing, the difference from one retailer to the next will typically be a few per cent.  All prices are posted.  I can decide if it is worth spending extra time and gasoline to save $2.  I need not buy the shirt that I will wear with it from the same place.  And if Jerry Garcia's pattern is too garish for the infrequent occasions that warrant a tie, I can get one with no pattern for maybe a little less.  I am a consumer who need not give a reason for why I opt for one purchase over another.  For very large purchases like houses or cars, there is some bargaining room, though the consumer is probably at a disadvantage over the professional agent.  Even so, the purchaser can see the home's neighborhood or the car's odometer.  It is not a blind purchase.  If somebody tried to sell a home far above market value, it wouldn't sell.

While the pharmacy seems different from other retail purchases, it is not modelled after a Middle Eastern shouk or a casino either.  We don't bargain our price, though apparently our Part D carriers can leverage what they pay and pass along to us or sometimes not pass along to us.  Nor do we expect a bargain on Ladies Wednesday or a discount if the right horse wins at Delaware Park.  Instead we are kept in consumer purgatory, wondering why some of what we experience makes little intuitive sense.  And it's hard to conclude anything other than our elected officials letting us down in some way.

So why is a generic medicine prebottled in India so much different in any stated price, even under the best conditions, than the other generics?  Patent law times exclusivity for the patent holder, and for safety, when a pharmaceutical goes generic, a single competitor will be granted exclusivity for six months to see if the post-marketing generic pill is indistinguishable in any detrimental way from the original.  Then it becomes open market, unless a manufacturer wants to corner that market by buying competitors or other legal mechanisms to remain the only production source past patent expiration.  A recent New England Journal of Medicine Perspective Article, using Suboxone as the focus, details the multiple ways a manufacturer can game the regulatory system to maintain post-patent exclusivity and exorbitant pricing that a free market would effectively tame.  https://www.nejm.org/doi/full/10.1056/NEJMp1906680

After forty years of signing prescription pads, becoming proficient at the medication options, including price, for most pharmaceuticals used for endocrine disorders, addressing complaints from patients and sales pitches from company representatives trained to get me to prescribe more, I thought my understanding would be better than it really is.  If transparency fails among experienced professionals, the consumers of their doctors' prescriptions have no chance of escaping what registers as "rip-off" and probably really is.  We need to start with a better understanding of why one generic has a cash price tag of $14 and another has a cash price tag a minimum of ten times that but often much more.  Somebody is making more money than a free market would dictate, some of us are being extorted or even victimized at the peril of our health, and some such as the retailers and distributors are caught in the middle.  We consumers deserve better from the officials we choose to represent us.  So do our students of all ages who we try to teach the superiority of fair markets that ultimately prevail in America, usually as correction of prior abuse, throughout our history.  Correction seems long overdue.

Medicare for All?

Among my Osher Institute classes has been a discussion session each week going on two semesters.  Topics vary as does level of expertise of the presenter and the presentation.  A medical professional, not physician though highly experienced in systems of medical care, selected Medicare for All as the topic.   It has made a ringing slogan for some political candidates, who I think really mean universal health coverage for all Americans, which expands the possibilities to a lot more than Medicare.  When Medicare took effect initially it replaced nothing other than some retirees having health insurance from their union or company pension.  It was also opposed by some important physicians organizations whose credibility never recovered.  Seniors and disabled people needed care that they couldn't pay for which means either they skipped what would be elective or their doctors and hospitals did not get paid for doing what could not be omitted.  It worked out well for the beneficiaries, for the practicing doctors, for the doctors in training, and for medical institutions.  The taxpayers did less well and the crystal ball gazers know the day of insolvency will come.

While Medicare beneficiaries are fairly secure except for prescription drugs which have supplanted a fair amount of surgery, and those workers or employers don't seem to mind their allotted contributions, most of the population is on the paying end.  If Medicare payments to providers do not adequately compensate the care given, then the cost gets shifted with higher payments from commercial plans and higher premiums or deductibles.  And we have a lot of Americans left out in the cold, people who may as well replace those seniors from the 1950's who could not forgo medical care but had no means of paying for it.

Most places around the world have bitten the bullet, offered universal medical benefits to their inhabitants, got some semblance of quality by accepted measures, and pay a lot less per individual than American aggregate costs, which don't cover everyone.  Medicare expansion sounds good.  An equitable system, something people are used to either for themselves or parents, and predictable if not economical cost.  Not a bad option if it didn't have to replace something, which is why some political candidates claim it as a promised initiative if elected.  However, it does have to replace something, and while uninsured or Medicaid or maybe even VA patients would do better, much larger numbers of people are already used to something else, often paid invisibly by employers supplemented by nominal payroll deductions that they never see.  Disruption never goes well, even when the status quo has a lot of room for improvement.  Siphoning off their care to create corporate infrastructure and profits does not register until the care fails, which it hasn't.

What struck me about the discussion with about a dozen Medicare age seniors of good intellect in the room was the shallowness of the understanding and the inability to articulate what they would want to accomplish.  From a patient perspective, it may be closer to VA or Medicaid for all though salaries would come from multiple employers.  Moving employees from their corporations to the Medicare rolls or people doing useful work for insurers to Medicare where the same work needs to be done but not necessarily by the same people or even the same number of people may not be worth the disruption.  And if everyplace else around the world has a process, the knowledge of those possibilities was non-existent, let alone how those places got from their starting point to where they are now.

The people in our room were 100% mullets but at least we have no influence on what happens.  The political candidates are also mullets and they can do a lot of harm.

While expertise has been gradually devalued, except maybe in the hi-tech world,this is one where people really need to defer to the experts who can examine other attempts,  determine intended upsides and downsides of multiple options, and pick one.  That's not a room of a dozen seniors and it's not a televised debate stage of ignoramuses seeking votes from other ignoramuses.

Medscape's Best and Worst

As each calendar year reaches its conclusion, many organizations attempt to compile best and worst lists, be it TV shows, movies, cars, people of prominence or infamy that bring character and maybe immortality to the year that will soon fade into history

Medicine like any other pursuit has its heroes and its scoundrels.  I would take a safe guess that all physicians can name in an instant the five teachers who shaped them and the five guys they thought should be reported to the state board, if not the FBI.   For the bad apples, we contented ourselves as residents to mostly scoring them with a lot of zeroes on our attending physician evaluation form but never pursued anything seriously punitive.  For the benefactors, we not only gave them higher scores but assimilated some elements of their revered practices into what became of us professionally forever.  We know who they are and what they did on our behalf, even if nobody else does.

We also come across medical colleagues who we do not know but find their way into the medical and secular news for their exceptional deeds that reach beyond our personal experience.  Some win Nobel Prizes, some swindle Medicare.  In recent years we have passively received enough lurid news in print or electronically that it registers as our daily expected dose of world affairs.  Some respond, most don't but file some imprint deep into the cerebrum where it might be retrieved if ever needed but does not stay with our awareness for very long.  At the other pole, when we attend our annual meetings, some physicians get awards while we sit in the audience and clap.  Professional achievement always gets our admiration.  We see the news of physicians gunned down, including a personal college friend killed in the Pittsburgh synagogue massacre or by a disgruntled patient, usually not the superstars of medicine but professional colleagues who get some combination of sympathy and honor for the dignity that their abruptly halted careers brought to the medical profession.

While our recognition of these physicians tends to have the trajectory of a funnel where stuff goes in the big end, gets concentrated and disappears in a moment out the small end, we are fortunate to have an organization like Medscape that identifies, catalogs, and retains these positive and negative outliers each year in an easily searchable way.  The list comes out in mid-December and is traceable at least back to 2011.  Being something of a news voyeur, I scrolled through the current roster as it came passively to my email inbox.  What makes physicians, and sometimes scientists, heroes or villains can be hard to tease out on one year's list, but by searching back about five years, laudatory and despicable themes emerge with some consistency, which may not be all that different than how we each individually assigned the best and worst physicians who we personally encountered between medical school and retirement.

The rascals have a lot more consistency, and most years larger numbers, than the exemplars.  With rare exceptions they have traded in their white coats for orange jumpsuits.  Some are outright predators, engaging in assaults on mostly female or pediatric patients.  Others engage in various forms of lucrative unconscionable care.  The scientists among us might call them errors of the First Kind, assigning significance to diseases that were not present.  The intent takes it outside the realm of error.  Patients without cancer received chemotherapy, normal coronary arteries got stented, inappropriate but systematic retinal photocoagulation, and any variety of excessive bodily invasions from sinus surgeries to repetitive skin biopsies.  While these docs seem more profiteers than predators, there is something inherently evil about intentional unneeded care.  Over the few years of my review, there were few overtly incompentents, other than a few surgeons functioning above their level of training, but generally medical schools and residencies produce capable people, though not always ethical people.  The next common category are the profiteers.  There are a lot of these.  They probably caused little bodily harm to vulnerable people so, in my mind at least, would fall one level less on my personal evil-meter.  They are more financial cheats than medical ones, though a few cut corners by obtaining less expensive medicines from authorized sources then billing for the real thing.  But mostly these doctors arranged for others to due financial processing of bogus services for financial gain but not medical harm.  There were a lot of these on each annual list.  And finally we have a handful of unfortunate people who offered suitable care but got videotaped engaging in mockery of patient or staff or fulfilling a dream of being a rapper while removing a body part.  Poor judgment probably, worthy of a worst of doctors list, probably not.

Medscape's best of doctors each year fall into more categories with too few to make generalizations of how the majority of practitioners can upgrade themselves to be more like them.  One common category of people worthy of admiring though not emulating are those whose recognition that year was brought about by their untimely death.  They did good work, for sure, but it was the car accident or plane crash while on a mercy mission that caused Medscape to include those physicians that year.  About an equal number also arrived on the annual recognition list by appearing in obituaries first.  These people had lifetime achievements, mostly in advancing the science of medicine.  Their CV's no doubt had a few awards while still functioning well enough to appreciate the adulation their work had earned.

There is another very large category of praiseworthy doctors whose medical knowledge and skill does not tower any higher than the rest of us, though their dedication and tenacity might.  Each list has physicians, mostly still alive and working, who enabled people at the margins of medical care to have better access.  Some travel into the Third World to bring this about.  Some set up rural clinics, some make a career of treating medical pariahs, the modern version of lepers perhaps, people who a lot of us would groan if we saw those patients on our schedule.

One final category that appears on every list, probably no more skilled medically than anyone else, but who endured unusual challenges to complete their medical degree.  These include professional and Olympic athletes, refugees from war zones partly completed with their education who had to flee and reapply with some difficulty in an unfamiliar country with a new language.  One started as a patient, a teenage surgical ICU alumnus with life threatening gunshot injuries who became captivated by what the surgeons were doing for him and then pursued his education under burdensome conditions but prevailed.  One does not need to be the most prodigious clinical or science maven to excel.  Pursuing a dream relentlessly is an option available to most of us in some form.

So what becomes of these people?  The medical scoundrels amass quite a lot of prison time.  Do they remain bottom feeders in custody, or might there still be some spark of benevolence that once got the favor of the Admissions Committee?  Do they sit in their cells and mope or do they impart the literacy skills and science aptitude that they have to be of benefit to other inmates who had less going for them at the time of their arrests than the doctors did?  There are medical reporters for Medscape and elsewhere that could pursue that direction.

And the Top Docs who are active, do they continue to inspire colleagues and patients with that same persistence they used to excel so that others might be more dedicated to self-management and responsibility for the diseases that they have?  Appearance on the Medscape exceptional list should have an enduring presence beyond the 15 minutes of fame or infamy that Andy Warhol thought all people are entitled to have.