American (Dysfunctional) Medicine

I am really frustrated.

I have a patient with significant chronic pain for whom I am trying to prescribe long-acting narcotic pain medications.  The reason you prescribe longer acting pain medications (like Fentanyl patches, MS Contin, or OxyContin) is to decrease addiction.  These medicines are to be used on a scheduled basis to help prevent pain from coming (or significantly decrease it).  Proper use of these medications can greatly decrease the use of short-acting pain medications (like Lorcet or Percocet) which are much more associated with addictive behavior.

For those who do not know, there is a difference between addiction and dependency.  While you often hear the terms used interchangeably, addiction generally refers to a pattern of behavior where a person uses a substance (or behavior) to increase pleasure and/or decrease pain.  Addicted people emotionally crave what they are addicted to (even things like shopping or gambling can be addictive) and are driven to it more when they are under emotional stress.  Classically, the shorter the onset of the substance, the more the risk of addiction.  This is why medications like Xanax and Percocet are more addictive.  The person wants the "buzz" from whatever they crave to help them deal with stressors in their lives.  In general, pathological addictions are harmful to the person, yet they are drawn to the pleasure nonetheless.  This makes the viscous cycle of addictive behavior leading to pain, leading to the increased impulse for addictive behavior.

Dependency is a physiological phenomenon where use of a substance can result in: 1) tolerance – where the substance gradually becomes less effective, requiring higher doses; and 2) withdrawal symptoms when the substance is stopped suddenly.  A good example of dependency is coffee.  I get a bad headache if I can\’t get to the coffee soon enough (usually by 11 AM – I\’m not that bad).  Afrin nasal spray is another substance where dependency occurs.  People become dependent on these substances, but the addiction is either mild or not there at all.  Things like gambling and shopping are obviously addictive but don\’t create dependency.

Anyway, I try to get my chronic patients on the long-acting medications to prevent addiction (although they will all eventually become dependent).  This is for the good of the patient.  Yet I have been nothing but frustrated by our Medicaid managed care company when I tried to get this person medication.  I would prescribe one, and they would say that it was not on the formulary.  When I asked what was on the formulary, they would give me another drug\’s name.  When I prescribed that one, it would then need an authorization.  This went on for 2 solid weeks, and finally was resolved today.  So basically what was happening was that the system funded by our government was forcing me to use medications that would create drug addicts.

This formulary game goes on day after day in the typical medical office.  We try to prescribe drugs for our patients, but the pharmacy will call us back and say it is off of formulary.  Often these are drugs the patient has been on for a long time and should be "grandfathered" on, but the people from the managed care company ignore that rule and deny the drug.  Formularies seem to change with irritating frequency, resulting in a huge amount of work for my office staff and frustration on my part.  We have numerous managed care companies for whom we must prescribe on their formularies or be eternally pestered.

Now, I once was on the dark side.  I was on the Pharmacy and Therapeutics committee for one of the largest HMO\’s in Georgia.  I appreciated the need for some control over the cost of prescriptions.  Physicians will often prescribe based on what the drug reps tell them or based on habit.  While generic medications may be just as effective, the tendency is for many physicians to prescribe name brands.  Formularies are one way to control this behavior and force physicians to follow guidelines.  Our committee was actually pretty good at considering what was reasonable.

But things have gotten out of hand.  The Medicaid MCO\’s are now not only requiring certain approved brand-name drugs, they are making us prescribe specific cough/cold medications as well (which are very inexpensive as a group).  This is not a cost savings, as the bureaucracy needed to maintain that is surely more costly than the savings gained by physicians prescribing the right cough medication.  Since this is from the government, there is no need to be efficient.

This is but one example of the daily frustration physicians in the US face.

In the Washington Post yesterday was the following article:

U.S. Health Care Deemed \’Dysfunctional\’

By CARLA K. JOHNSON
The Associated Press
Tuesday, May 15, 2007; 5:35 PM

CHICAGO — The U.S. health care system is "a dysfunctional mess" and politicians who insist otherwise look ignorant, according to a medical journal essay by a prominent ethicist at the National Institutes of Health.

"If a politician declares that the United States has the best health care system in the world today, he or she looks clueless rather than patriotic or authoritative," Dr. Ezekiel Emanuel wrote in Wednesday\’s Journal of the American Medical Association.

Emanuel, who supports sweeping health care reform, said the U.S. spends $6,000 per person per year on health care, an amount that is more than 16 percent of the nation\’s gross domestic product and more than any other country.

He also said Americans\’ average life expectancy of 78 ranks 45th in the world, behind Bosnia and Jordan. And the U.S. infant death rate is 6.37 per 1,000 live births, higher than that of most developed nations.

President Bush frequently has said Americans have the world\’s best health care system, but Emanuel stopped short of calling Bush clueless in his essay and during an interview with The Associated Press.

"I work for the federal government. You can\’t possibly get me to make that statement," Emanuel said in the interview.

Emanuel\’s proposal involves phasing out Medicaid, Medicare and employer-sponsored health insurance. Under his plan, all Americans would get a basic package of insurance, would choose their insurance carrier and could buy upgraded coverage. The program would be funded by a value-added tax of about 10 percent on businesses.

Democrats and Republicans alike have made the "world\’s best" claim. Democrat John Kerry did so when he ran for president in 2004, as did Republican Rudy Giuliani on the presidential campaign trail this year.

David Hogberg, senior policy analyst at the National Center for Public Policy Research, said a strong case can be made that the U.S. health care system is the best.

"It depends on what measures you use," Hogberg said. Life expectancy is influenced by many factors other than health care, he said, and nations measure infant death rates inconsistently. Other measures show the United States performing well, he said.

Hats off to Mr. Emanuel.  I am not sure about the details of his plan (and the devil lives there usually), but he is pointing out the elephant in the living room that many wish to ignore.  Our healthcare system is a mess.  How could a system that requires a full-time employee equivalent to sort through the nightmare of formularies be the "best system in the world?"  We are paying a huge amount for a system that yields sub-par care.

How broken is the system?  That is a matter of perspective.  Yes, there is room for debate on the degree of dysfunction, but the system clearly is dysfunctional and is getting worse.  From the loss of primary care physicians to the increasing number of uninsured in this country, the trend is clearly for more dysfunction in the future, not less.

So plug your ears and hum when you hear the pundits telling you how good our system is.  Yes, we have some very good physicians doing remarkable things, but the system we have now is incredibly inefficient and frustrating.  That frustration sometimes tempts even this physician to wash away that stress by throwing back a cold one.