THE BUSINESS OF HEALTHCARE - As the old saying goes, the "Perfect is the Enemy of the Good".
Unfortunately, in its well-meant and arguably over-reaching effort, the Democratic Congress of 2009-2010 enacted an Affordable Care Act that appears anything BUT affordable--and, unfortunately, the Republican "free market approach" hasn't been working either, as exemplified by the "Doxycycline Debacle".
In short, there are so many evil-doing, profit-driven entities tied to the "free market" and our federal government that it's very hard to figure out who to call out first. And--both increasingly and alarmingly--you cannot trust even that most historically-trustworthy health care professional: the pharmacist.
But it's not all bad, and so let's back up and give you a historical perspective:
I am a dermatologist, and in addition to "wear your sunscreen" and "moisturize daily", my profession has a storied history of being focused on infectious disease. Before HIV, and before antibiotics, the "AIDS of the Western World" was syphilis, and the old dermatology journals were entitled something like "Dermatology and Syphilology". Syphilis and tuberculosis (the other "AIDS of the Western World") were that huge, and that frightening.
After antibiotics were developed, and when outpatient surgery started liberating patients and doctors from hospitalizing all surgical patients, and when AIDS suddenly reared its frightening head in the 1980's, things shifted in dermatology. Dermatologists started doing things that ENT, General and Plastic Surgeons did, and the field of Infectious Disease sprung up in a manner that changed my specialty into a more surgical and less medical one.
That said, dermatologists are still focused and obsessed with infectious disease, the mechanisms of inflammation, cost-effective healthcare options and innovative new treatments.
So when doxycycline, a medication which over the years has increasingly been focused on its anti-inflammatory effects, suddenly disappeared a few months ago from the pharmacies and came back about ten times as expensive, we were infuriated and baffled...as are patients, other doctors, and pharmacists.
I love doxycycline so much I could marry it. It is both effectively anti-infectious even to penicillin-resistant skin and internal infections, as well as potently anti-inflammatory for skin diseases that are not infectious. Sterile, culture-negative leg wounds respond to doxycycline. Acne and rosacea respond to doxycycline...and while 50% of the general population now has penicillin-resistant bacteria now growing on its skin, doxycycline still is, overall, quite effective.
Hence the supply/demand change in price for doxycycline, and the great interest in differing doses of the medication to reduce its significant gastrointestinal side effects, or to create a dose which is anti-inflammatory but not anti-infection so as to reduce both side effects and its potential to create a new form of antibiotic resistance.
I saw pharmacists and doctors (including myself) resort to branded doxycycline derivatives because generic doxycycline, after it had come back from its mysterious disappearance, had jumped from about $15-25 to $170. A heretofore cheap, easily available drug became suddenly an expensive, hard-to-obtain medication...and while I cannot successfully conclude that there was inappropriate and unjustifiable price manipulation, I have a very hard time ruling it out.
And with the understanding that I've seen generic medications--virtually all of them--priced at 5-10 times the price that they should be charged because they're decades-old and made for pennies, one BIG MYTH must be exposed:
DO NOT PRESUME, UNLESS YOU HAVE A LOW DEDUCTIBLE AND GREAT INSURANCE, THAT GENERIC MEDICATIONS ARE MORE COST-EFFECTIVE THAN BRAND-NAME MEDICATIONS.
To those reading this, let me proclaim that this is a horrible reality that must be reversed. Even if you're not paying cash for your medications, your health plan is...and your premiums are going up, accordingly.
So while I do support Medicare setting the stage to confront both brand-name and generic pharmaceutical companies on their pricing, and am sick of both overpaying for even the cheapest of medications and subsidizing Canada and Europe on drug costs (they pay roughly a third of what Americans pay), the answers remain elusive.
My own silly and perhaps unrealistic option: have health plans and insurers create non-profit pharmaceutical companies that have one primary function--to drive costs down, and to make more decades-old medications remain squarely in the $5-25 range.
Right now, we have health plans and pharmaceutical companies behaving more like oligopolies than competitive free-market entities. Even worse, we also have pharmacists in major pharmacy chains who've been unable to shake the accusations that they have their incomes tied to the number/percentage of generic medications they prescribe--even to the point of being untrustworthy when denying brand-name rebate cards that could save hundreds of dollars and subsidize the deductibles of patients.
I cannot prove anything, but I can tell you (run this by your own doctor/PA/NP, and he/she will likely confirm this to you) that when Walgreens, CVS or Rite-Aid tell me that a medication is not covered, or requires a prior authorization form for that medication despite having given the patient a pharmaceutical company rebate card (and which my computerized medical records tell me it's covered), I cannot know if the pharmacist/pharmacy staff is being truthful.
And while pharmacists will deny it, there are too many of my colleagues in or tied to pharmacy chains that will confirm that their incomes are tied to generic switching/percentage of filling. So let me bust another BIG MYTH that must be exposed:
THE ERA OF THE TRADITIONAL TRUSTED PHARMACIST IS CURRENTLY OVER, IF THAT PHARMACIST IS FROM A BIG CHAIN PHARMACY.
This is not to say that some individual pharmacists will hold true to their core values, but medical providers now usually recommend their cash/high-deductible patients do the following:
1) Go to Costco. Their corporate culture is such that if they call and report that a medication isn't covered, it's almost like the word of God.
2) Go to Walmart or Target, which have a list of generic medications for $8-25, which is frankly what they should cost.
3) Use brand-name rebate cards and save hundreds of dollars, and even potentially have part of your deductible subsidized by the pharmaceutical company making the drug you want. I wish I could say that generics are always the same as brand-name medications, but it's not always true.
Time and space prevent me from addressing other cost-related issues regarding healthcare, but suffice it to say that evidence abounds that Obamacare will NOT lower health care costs. And plenty of union and governmental workers want no part of it. Those issues will be addressed in future articles.
The bad guys are all around you--including many doctors and medical providers who aren't always looking out for the public interest.
The answer will probably be a combination of Democratic head-bashing and Republican free-market promotion--so you partisan zealots might just want to hold your breath, acknowledge where you don't know everything, and maybe even listen for a change and learn something.
But the Doxycycline Debacle is part of a growing element to our societal culture of grabbing what you can, however you can, and as quick as possible--and let the suckers focus on morals and honesty.
And as a physician who sees the middle class as falling ever more into poverty, I am sick of it.
Maybe I need some doxycycline to feel better...but then again, maybe I can't afford it.
(Ken Alpern is a Westside Village Zone Director and Boardmember of the Mar Vista Community Council (MVCC), previously co-chaired its Planning and Outreach Committees, and currently is Co-Chair of its MVCC Transportation/Infrastructure Committee. He is co-chair of the CD11 Transportation Advisory Committee and chairs the nonprofit Transit Coalition, and can be reached at Alpern@MarVista.org He also co-chairs the grassroots Friends of the Green Line at www.fogl.us. He is also a Board-Certified Dermatologist. The views expressed in this article are solely those of Mr. Alpern.)
Vol 11 Issue 34
Pub: Apr 26, 2013