Recently it was reported that a common anti-inflammatory medication (Aleve) caused an increase in heart problems or stroke in patients being studied to see if it helped Alzheimer’s risk. Another common medication, Vioxx, was taken off the market after studies showed that long term use increased risk of heart problems. A major problem is that the FDA over emphasizes short term studies and the wealth of clinical experience is not systematically monitored. The media contributes to the problem. Medications that help people feel better or raise their quality of life don’t make news. That wouldn’t increase ratings. It’s the juicy stories that get the press.
Last year, a report on a study of hormone treatment in menopausal women claimed that hormone therapy causes increased heart problems, strokes, and cancer. On the Today Show an author was interviewed saying basically that pharmaceutical companies have misled doctors and the public. The author further stated that they have profited by misrepresenting the benefits of hormones and failed to report dangerous complications. The interviewer’s response was "a lot of us women are mad that we have been so deceived." The truth of the matter is that less than half of menopausal women were on hormones at the time and up to half of the ones that were on hormones stopped them after the report came out. Insurance companies fearing an avalanche of law suits, put pressure on physicians. Some insurance companies told gynecologists they wouldn’t cover complications of hormone treatment other than short term use. For this and other reasons many doctors advise their patients to get off hormones. My knowledge of the limitations of studies and more importantly my clinical experience all lead me to believe at this time the benefits both short term and long term (especially for the brain) outweigh the risks for most menopausal women taking hormones.
Another example of media impact is that of Michael Moore. He is currently working on an expose of the pharmaceutical industry. He is allegedly paying physicians, pharmaceutical reps and others to provide the "inside scoop" on the workings of the pharmaceutical industry. On a recent Today Show he described the pharmaceutical industry as evil. Katie Couric’s attempt to get him to admit that the industry does provide us with new and better treatment was met with sarcasm and contempt. He gave an example that Eli Lilly had known for years but kept secret that Prozac, a popular treatment for depression and anxiety, increased the risk of suicide 12 times. My reply to this is, "do you think it would still be on the market if it was that dangerous?" He made his statement as if it were fact. A lot of people see him as a folk hero. I like that in America we are free to say what we believe. I’m exercising the right of free speech now. What I don’t believe in is the right to present opinions and distorted information out of context, and quote uninformed sources as though they are well researched fact. Satire should not be presented as a documentary. It does a lot of harm. But it gets the ratings and makes the money, and after all this is America.
What role has managed care (more honestly, managed cost), played in changing the way medical care is provided? The idea of a system that improves the quality of medical care is a good one. But over the past two decades I believe the result has been more the opposite. When I first started treating patients in the private sector, (early 70’s), decisions about medical tests, hospitalization, and treatment were made between the patient and doctor. Insurance would help with the cost depending upon the specifics of the policy or health care program. Medications were mostly generic. As health care costs escalated, insurance company profits began to shrink and the cost to employers was increasing at an alarming rate. Thus, the managed care system was born.
Managed care now monitors care and has the right to approve or not approve tests, hospitalization, or treatment. The decisions about care were gradually taken away from the patient and the doctor. Of course, the patient is always free to pay for healthcare themselves, but the costs are usually prohibitive.
The managed care companies became a fourth player in this process. They justified their existence by reducing the amount of dollars insurance companies had to pay – the managed care company would then get part of the savings for their profit and cost of doing business. So, in effect, the insurance companies would sometimes save 30% (20% of which would go to the management company). The insurance companies were happy, the employers were happier because they had more cost containment, the management companies were happy they had a job, BUT the poor patient now has about 30% less help with care and mainly has been out of the loop. In addition, the management companies contract with certain physicians who help "contain costs". This would insure that the physician gets a certain volume of patients with guaranteed but reduced payment for their services.
So how does this change the way physicians provide care? Almost always it means less time for the patient. The visit is shorter, and maybe less frequent, and tests are harder to get approved. Certain medications (cheaper generics) are more likely to get approved. Although I stopped accepting insurance (control) for my services a few years ago, I must still get involved frequently with having to request approval for medications that I feel are the best for the patient. Recently, I asked an insurance company to approve Provigil, a medication that increases alertness, and is also used for narcolepsy, shift work, and many other causes of excessive sleepiness. This was the only medication that I could find that one of my patients could take that would allow her to stay awake at work and not cause any side effects. After two letters pleading our case we were still denied. Why? COST. The insurance company felt that the drug was too expensive so the patient was "out of luck".
