More Provocative Articles on the Health Care System

This week was a good one for health care articles.  There were 3 in particular that caught my attention and resonated with me.
 

1.      “The $2.7 Trillion Medical Bill” in today's The New York Times :

http://www.nytimes.com/2013/06/02/health/colonoscopies-explain-why-us-leads-the-world-in-health-expenditures.html?ref=health

2.     "Finding the Right Hospital" in The Atlantic on May 28^th:

http://www.theatlantic.com/health/archive/2013/05/finding-the-right-hospital/276304/

3.      "A Lone Voice Raises Alarms on Lucrative Diabetes Drugs" in The New York Times on Friday May 31st:

http://www.nytimes.com/2013/05/31/business/a-doctor-raises-questions-about-a-diabetes-drug.html?ref=health&_r=0

 “The $2.7 Trillion Medical Bill” reminded me of the Time magazine article by Steven Brill a few months ago on the same subject.  The main points were about the variability in costs across different locations for the same procedure. Most patients don’t know how much a procedure costs until after it is done and the insurance company has processed or denied their claim. Both articles compare prices of medicines and procedures across the world, showing that the US has the highest costs.

Just this past week, I reveived my reimbursement information from Aetna, my health insurer.  My Sandostatin shot for April was billed to Aetna at $13,343 and reimbursed at $8,757.  My March Sandostatin shot at the same dose was billed at $5,000 and reimbursed at $2,722.  I recently changed doctors but I can’t imagine why two centers can charge such widely different amounts for the same shot!  I called Aetna to find out what was going on and the person I spoke with said that different centers have their own reimbursement rates for procedures and that the Sandostatin shot may be more expensive but other procedures may be cheaper.  I also believe the price of Sandostatin may have gone up because I’ve seen a few postings about that on the ACOR online message board.  I guess as long as my insurance company is covering it, I shouldn’t worry but it does make me a bit crazy!

I think it would be helpful if there were more standardization of prices and if it were possible to know up front what everything would cost.  It would make it much easier to decide which procedures to have, to shop around for better prices and to make sure that medical costs would not cause financial hardship. 

The second article covers patient satisfaction ratings and how, if at all, that may influence where one should go for treatment.  It was very interesting because patients may not be the best people to evaluate their medical care. The article cites some examples where the ratings are high but the outcomes are worse.  One commenter on the article stated “The closest analogy to hospital care is auto body repair. Both are insurance-paid and cost insensitive. And in each case the customer generally presents in distress, either by ambulance or tow truck, and in no position to choose. While both may advertise quality of service the customer is unable to judge that quality unless things go drastically wrong.”

As more hospitals publish patient satisfaction scores and more healthcare professionals are being compensated based on these factors, it is becoming a controversial issue.  One of the blogs I read, “Skeptical Scalpel”, shown on my blog list, frequently deals with the issues involved in hospital/doctor ratings.

The third article deals with a Dr. Peter C. Butler who found that a class of diabetes drugs may cause pancreatic cancer. It states in part: “Public Citizen and the Institute for Safe Medication Practices, two watchdog groups, have both arrived at the same finding….Dr. Butler faces powerful opponents in the makers of the drugs and many diabetes specialists, who say his studies are contradicted by other evidence….More information could come out in June when the National Institutes of Health will hold a two-day meeting on possible links between diabetes, diabetes drugs and pancreatic cancer. Dr. Butler will be one of the speakers.”

This article is less relevant than my usual rants but it just reinforces my concerns about the influence that big pharma has on the type of information that is released to the public and regulatory agencies. Both the effectiveness and potential hazards of drugs may escape public scrutiny until the class action lawsuits begin.

 

These articles continue to highlight the major problems and potential solutions within the US healthcare system. I’m not sure how things will ever change from the convoluted mess that we have now.

Happy 1st Birthday to Beth’s Adventures with Carcinoid Cancer!

Today marks one year of writing my blog.  When I started posting, I was frustrated by my experience in the medical system and concerned that I did not have a doctor that I could trust.  Now I am on my third carcinoid specialist and feel comfortable that my doctor is working with me not against me and that there is a strong team backing her up.  I’m still frustrated with the medical system but have learned that I can’t change it so I will work with it. 

I didn’t really have any expectations for this blog except to discuss my experiences and vent my frustrations.  As of today, Beth’s Adventures with Carcinoid Cancer has had 10,000 visitors!  I’m quite happy that the blog reached that milestone so soon and exactly at the one year mark. Over the past year, I’ve met some nice people and learned a lot from my writing experience. Not being a super savvy computer user, I’m not sure if the 10,000 visitors are distinct users or could be 1,000 different people visiting 10 times each. 

I am a bit of a data geek so I find it interesting to look at the numbers that Google gives concerning visitors.   For example, the top 3 posts are as follow:

Post	Number of Visits
The Difference between a Flush and a Hot Flash	920
September 11th	666
Bitter Pill and Gorillas in CT Scans	325

I think a lot of people get here by asking a search engine “what is or how do you tell the difference between a flush and a hot flash?” Then my blog comes up.

When looking at where the visitors come from, it is very US focused but many visitors have also come from overseas.  Just yesterday there were 20 visitors from Jordan!  I wonder how that group found this blog on the same day – perhaps they were together in a class? The table below shows the top 10 countries visitors came from:

Location	Number
US	6,160
France	709
Germany	380
UK	355
Russia	240
Canada	172
Sweden	102
Australia	66
Mexico	49
Singapore	40

I also get information on what operating system and browser the visitors are using and it looks like this:

Operating System	Percentage
Windows	74%
iPad	7%
Macintosh	6%
iPhone	5%
Linux	2%

Browser	Percentage
Internet Explorer	33%
Firefox	28%
Safari	17%
Chrome	11%
Opera	5%

Other information that I can’t get from online users are facts such as whether more women than men are viewing my blog, their average age or the type of cancer they have. I’m guessing that more women than men are viewing it because of the popularity of the flushing vs. hot flash post.  It could also be because that post mentions “Fifty Shades of Grey”.

Overall, I’m in a better place now than I was last year at this time and I think this blog has helped me get there.  On to year two!

The Cancer of Optimism

In yesterday’s New York Times, there was an Op-Ed about doctors being overly optimistic with their patients about their prognosis.  It was written by a resident physician just starting his medical career.  He discusses a patient who unexpectedly died.  The writer called himself a “victim of irrational optimism, a condition running rampant in both doctors and patients, particularly in end of life care”

He goes on to quote some statistics from a cancer study from The Annals of Internal Medicine in 2001 that stated “doctors were up front about their patients’ estimated survival 37% of the time; refused to give any estimate 23% of the time and told patients something else 40 % of the time. Around 70% of the discrepant estimates were overly optimistic”.

“This optimism is far from harmless.  It drives doctors to endorse treatment that most likely won’t save patients’ lives, but may cause them unnecessary suffering and inch their families toward medical bankruptcy.”

“Studies have shown that patients almost universally prefer to be told the truth.  If physicians cannot deliver the hard facts, not only do they deprive their patients of crucial information, but they also delay the conversation about introducing palliative care.”

He does on to cite a study that showed that cancer patients who had palliative care combined with standard care lived a few months longer than those with standard care alone.  The writer went on to state that nonetheless, doctors usually insist on more invasive treatments even when there is little chance that they will work. 

It appears that patients are not being given truthful information about their prognosis and how effective the next invasive treatment will be. Doctors are telling patients to undergo more invasive treatments because they are hoping they might work.  The problem is that these procedures lower quality of life without much extra longevity. 

If I get to the point where a new treatment is not likely to work, I would hope that my doctor would tell me to enjoy the rest of the time I had without furthering invasive procedures if they are futile.

The Op-Ed can be seen in the link below:

http://www.nytimes.com/2013/05/05/opinion/sunday/the-cancer-of-optimism.html?pagewanted=all&_r=0

Novartis – At it Again with Kickbacks Disguised as Rebates and Discounts

Last week, the US Department of Justice (DOJ) filed 2 federal lawsuits against Novartis.  One complaint seeks damages and civil penalties for corrupting the dispensing process with multi-million-dollar ‘incentive programs’ that targeted doctors. The other involves kickbacks in the form of rebates and discounts to at least 20 pharmacies in exchange for switching transplant patients from rival medicines to its Myfortic, an immunosuppressant treatment used to prevent rejection of kidney transplants.

The allegations have a familiar ring, given that the feds have made similar charges against many drug makers over the past decade. Payments and ‘lavish’ dinners given to doctors were purportedly kickbacks to seminar speakers and attendees to induce them to prescribe different Novartis meds. However, the feds say, some programs never actually took place or, if they did, doctors never spoke about the drug at issue.

This is the second time Novartis itself has been hit with this type of lawsuit.  The first was settled in September, 2010.  It specifically included Sandostatin as one of the drugs that the company was paying kickbacks to doctors to prescribe.  I discussed this in my blog post titled “Who’s Paying Your Doctor?” on June 24 2012.

The link to the 2010 case is below:

http://www.justice.gov/opa/pr/2010/September/10-civ-1102.html

As part of the 2010 settlement, Novartis signed a Corporate Integrity Agreement (CIA) with the Department of Health and Human Services, Office of Inspector General (HHS-OIG). The company is subject to exclusion from Federal health care programs, including Medicare and Medicaid, for a material breach of this CIA and subject to monetary penalties for less significant breaches. 

As the feds make clear in their recent lawsuits, the alleged kickbacks to doctors and pharmacists took place before and after the CIA was signed. This is a potentially huge problem, because it could mean that Novartis may face exclusion as defined above.

I am not sure exactly how exclusion works but if some of the Novartis drugs that were involved in these lawsuits, particularly Sandostatin, become excluded from the list of drugs used by Medicare/Medicaid, this would be devastating to cancer patients. Exclusion, while it is a strong motivator to change behavior, would seriously impact patients who rely on the Federal programs for their healthcare.  An alternative to exclusion might be to have the DOJ force Novartis to provide these drugs to Medicare/Medicaid at no cost.  This would hurt Novartis but would not cause patients to suffer.  I'm not sure if this is legal but it makes no sense to harm patients because of wrongdoing by Novartis, pharmacists and doctors.

Meanwhile, the DOJ goes on filing civil lawsuits against drug companies that continue to settle for higher and higher amounts of monetary penalties while denying any culpability.  Perhaps stronger remedies are needed including criminal penalties and prosecutions. 

This story is outrageous! Unfortunately, Novartis is not the only pharmaceutical company to face these charges.  It amazes me how these lawsuits/stories are filed on Fridays so there is not much media coverage of it over the weekend.  This is an age old public relations gimmick that still seems to mislead the public.

Source material:  Forbes: http://www.forbes.com/sites/edsilverman/2013/04/27/did-novartis-violate-its-corporate-integrity-agreement/

The New York Times:  http://www.nytimes.com/2013/04/28/opinion/sunday/another-alleged-drug-kickback-scheme.html?partner=rssnyt&emc=rss&_r=0

Dana Farber Cancer Institute

After several months of searching, I have decided to move my carcinoid cancer care to Boston’s Dana Farber Cancer Institute (DFCI).  It seems strange to go all the way to Boston for my care but I’ve had some difficulty in communicating effectively with the doctors I’ve seen in New York City.  I have family and business in Boston, so it’s not like I never go there.  I decided to look into DFCI for several reasons:

•  It is a large multidisciplinary system. I believe they may be a bit more conservative than some of the other carcinoid cancer treatment centers. 
• They have a large neuroendocrine tumor program.
• They have a reputation for an emphasis on patient care in addition to research. 
• Last year, I saw Dr. Kulke and Dr. Clancy speak at a conference sponsored by the New England Carcinoid Connection (see blog post from June 11, 2012). I was impressed with their knowledge.  I also met some of their patients at the conference. 
• It’s not that far from New York City.

I had my first consultation in January with Dr. Jennifer Ang Chan, an oncologist who works with Dr. Kulke, to discuss my circumstances.  I found her to be very articulate and clear.  I asked many questions at this appointment and she was very patient and spent time giving me thoughtful responses. I have been having trouble getting basic information from my other doctors, so her attitude was refreshing.  Dr. Chan is a straight talker – no abstract thinking, analogies or silly answers.  She reviewed my test results and scans and said that she would consult with Dr. Thomas Clancy, who is their neuroendocrine surgeon. She was concerned with the large tumor below my liver and in front of my kidney and thought it might need to be removed.  Dr. Chan said that DFCI does usually not do the very large exploratory surgeries that can take 6-8 hours trying to get everything out, especially when the surgery will not be curative.  They will target a certain potential risk and take tumors out of that area. 

I had two more appointments with Dr. Chan and Dr. Clancy, one in February and one last week.  Dr. Chan showed me an area of my abdomen from a CT scan that showed the large tumor already causing an indentation in my small bowel.  She said that they would normally not do surgery on an asymptomatic patient but since this tumor was already pressing up against the small bowel, any tumor progression could cause a bowel obstruction.  She also mentioned that the median time to progression for Sandostatin LAR users in the PROMID study was 14 months and that I have now been on Sandostatin LAR for over 24 months. The combination of these two factors was the concern in my case.

Dr. Clancy agreed with Dr. Chan and said that he normally wouldn’t do surgery on an asymptomatic patient, but that my large tumor (10x8 cm) pressing on my bowel, should be removed because any progression could cause a bowel obstruction.  He said that it was best to do the surgery while I was in good health and that the procedure would be much less complicated than if I had it done on an emergency basis after a bowel obstruction.  Dr. Clancy added there is a near certainty of future problems if I don’t have the surgery.  The surgery he is proposing will remove the large tumor, another large (6x3 cm) tumor in my pelvic area as well as some of my small intestine, affected lymph nodes, gall bladder and maybe my right colon.  Much of this would depend on what he encounters during the surgery.  He is quite confident that he will find and remove my primary tumor while operating on my small bowel.  The doctor plans to remove around 80% of my tumor load.  The surgery would last 3-4 hours. Recovery will take about 6 weeks. This is not different from what I heard from Dr. Liu and perhaps what Dr. Warner was trying to tell me.   Dr. Clancy seems very competent and concerned with quality of life issues after this surgery.  The surgery would be at Brigham and Women’s Hospital (BWH) in Boston.

This is a very difficult decision for me.  However, I am finally seriously thinking about it.  I have not scheduled it yet and I think I may wait until September to have this surgery unless someone gives me a good reason why I need to do it now.

I am very relieved to find doctors that I can talk to, who listen to me and that I feel comfortable with.  Both Drs. Chan and Clancy are smart, compassionate and punctual and listen to my questions and concerns.  It’s a welcome change.