Reform or Innovation: Common Sense Should Prevail

This week I ventured into the blogosphere in search for updates or any innovative idea that may contribute to the momentum of health care reform. Soon after Google’s announcement of its health initiative on February 28, I wrote about the benefits a national health information storage system will bring. I am delighted to find the post, “Health 2.0: Getting in PHR, Privacy and Deborah Peel issue off my chest,” written by Matthew Holt. He provided very sharp counter arguments to the allegations that such information would violate patient’s privacy. By separating myth from reality, he brings common sense back into discussion of such an important subject. According to Matthew, the real issue is not of violation of patient’s privacy, but is in the inefficient use of medical data that causes harm and wastage. I found another post, “Concierge Medicine from a Doctor’s Perspective” by David R. Donnersberger , MD, JD, very interesting. Though it is not a brand new topic, this business model appears to be gathering momentum. Under “boutique medicine” or “concierge care,” physicians ask patients to pay an annual retainer fee. In exchange, patients get greater access and personalized service. According to Darin Engelhardt, the Chief Financial Officer and General Counsel for MDVIP, a Florida based company that helps doctors transition to boutique practices, “95% of the company’s 40,000 patients renew their annual memberships each year. The business model appeals to over-worked and over-booked physicians. I wish to present my comments on these two posts for you below.

"HEALTH 2.0: Getting the PHR, Privacy and Deborah Peel issue off my chest"
Comment:
Thank you for drawing our attention to the right focus. As you wrote, “the biggest problem with the United State’s health care system and its use of technology is not privacy violations. It is the inefficient use of data causing harm (and costs and poor quality care).” You managed to introduce common sense back into the discussion; the setting up of national health care information adds no additional risk to patient’s privacy rights than what actually exists now. The information uploaded to the system is a mere copy, not the original. In fact, what is uploaded can be de-identified, thus offering patient privacy protection. Naturally, a well-designed system will preserve consumers’ right to decide who gets access to the data. Perhaps, consumers or patients may specifically block insurance companies, financial institutions, and employers from accessing the information. This will address the concern that these business entities may use the information to deny insurance coverage, loans, or employment, which creates whole new classes of people who are unemployable, uninsured, and dependent on the government, as Dr. Deborah Peel of Patient Privacy Right Foundation claimed. I believe consumers will appreciate that with Microsoft, Google, and Dossia getting into the business; the overall PHR industry privacy quality will improve. The Health Insurance Portability and Accountability Act, written before any PHR vendors came into business, is not updated but can be amended or modified to come up with a broader “covered party” definition, and to standardize patient privacy disclosure code for PHR vendors requiring the sale of data only in a de-identified format. We therefore should not use any loophole in HIPAA (logo shown to the left) to deny the value of a national health information system. A consumer will share personal information if there is a return or benefit. A borrower gives up his/her social security number in the loan application and allows a bank to access his/her credit report. We provide our medical history, together with the social security number and other personal data in the purchase of a health insurance policy. As a traveling person, I want my personal health information on a system that is secure, accurate, and readily available to those who need to take care of me, especially in times of an emergency. What good is my personal privacy will do for me if I no longer exist to give meaning to it.

"Concierge Medicine From A Doctor’s Perspective"
Comment:
Thank you for sharing this growing trend. I believe that our health care system is very vibrant, notwithstanding its shortcomings and challenges. Consumerism and capitalism play a big part in our health care system. Consumers want choices, and service-providers seek returns. Boutique medicine or concierge medicine (as shown in the image to the right) meets both expectations. I am not suggesting that financial reward is everything in our economic system, nor is the only deciding factor in a supply and demand equation. For a physician, a small client base means more time devoted to patient care and advocacy, along with continuing medical education and family life. While a care-giver may have to sacrifice financial gains, getting greater satisfaction from long-standing doctor-patient relationship offers a different kind of gratification, which an over-worked, over-booked physician will miss. A reduced patient load for physicians often translates into longer and same-day appointments, better coordination with specialists, and more emphasis on preventive care. Concierge care may potentially result in a two-tiered medical system based on wealth of the patients. Some decry concierge care as another step toward a medical system in which the rich get no-wait examinations and the poor sit for hours just to see a HMO doctor for 15 minutes. This is simply the nature of a free market. According to one comment on your blog, in Europe, where the universal health care system is long established, a significant percentage of people pay out-of-pocket to see specialists, avoid long waiting rooms, get MRIs, more appointments sooner, or see a doctor who is said to have better training or personality. While the concept sounds ideal, my concern is that physicians who choose to take part in this boutique medicine business model may not cancel all their contracts with third-party or government payers. As a result, doctors simply commercialize the doctor-patient relationship, and patients who pay the fixed annual fee in anticipation for premium services and attention will not get their bargains. Such business model is not widely available. According to the General Accounting Office, in 2004, there were just 146 concierge physicians in the U.S. My other concern is what will happen to the established doctor-patient relationship when one party has to relocate, especially for a patient who is very accustomed to a concierge care moves to a new region where such service is not available.

Public Trust Matters: Keeping the Big Pharmaceuticals In Line

In my previous post and following Google’s announcement to launch a personal medical record service, I raised the hope that the United States will eventually have a national health information storage system that will help deliver better care, lower costs, and reduce medical errors, in spite of some initial resistance. I believe such resistance can be overcome over-time since the American society has a good track record of embracing internet technology. Underlying that optimism is that public trust remains unshaken by the conduct of health care community – care providers, the pharmaceutical industry, and health insurance companies. Big, publicly-traded drug companies are powerful players in the health care community because of their financial resources as well as their control over the new drug supply. Unfortunately, they do have a questionable reputation through years of careless product launch, aggressive marketing tactics, and to a lesser extent – overcharging the public and the government. Although these companies are financial giants, they can be nudged into building better public confidence, as some of their perceived influence could be exaggerated.

The latest confidence-shaking incident involved Merck and Schering-Plough, who manufactured the drugs, Zetia and Vytorin, a combination of Zetia and Zocor, to treat high cholesterol. Worldwide, about five million people are now taking the drugs, according to a New York Times report. A two-year clinical trial that ended April 2006 raised questions about the medicine’s effectiveness and about the behavior of the pharmaceutical companies. The trial was meant to prove that Vytorin’s combination of Zetia and Zocor would reduce the growth of fatty plaque more than Zocor alone. Instead, the plaque actually grew almost twice as fast in patients taking the combination. Due to the drug’s significant contribution to their profitability, it aroused suspicions that the companies had deliberately delayed the release of data two years after the trial ended. The House Energy and Commerce Committee is investigating the delays.

Reflecting the general public suspicion about the drug companies' marketing activities, there are many articles written about their influential relationship with physicians. Part of the $671 million settlement, which Merck announced on February 8, 2008, was related to charges that it gave doctors freebies and gifts to induce them to prescribe its drug. As reported in the New England Journal of Medicine (November 2007), Eric Campbell, the co-author of the survey report, disclosed that over 90% of physicians take something from drug companies. The most common freebies are food and drug samples, which about 80 percent of physicians reported receiving, a smaller percentage (25-35 percent) of physicians reported receiving substantial payments in the form of reimbursement for professional travel, consulting, and servicing on speaker’s bureaus or advisory boards. According to Eric Campbell, "Although most physicians deny that receiving free lunches, subsidized trips, or other gifts from pharmaceutical companies has any effect on their practices....companies wouldn't spend $19 billion each year establishing and maintaining them [if this strategy didn't work]."

It is unrealistic to expect the big drug companies will not aggressively market their products, having invested a large sum of money on research and development. According to the Congressional General Accounting Office (GAO), the pharmaceutical industry spent about $30 billion on R&D, and about $20 billion on marketing and advertising. About half of the $20 billion is accounted for by the free medicine provided to doctors. The big drug companies maintain their relationship with the physicians through the large army of drug representatives, who are, by and large very intelligent and good at cultivating personal relationships. I believe such contacts or relationship is necessary and helpful, if it is limited to carry out informational programs. Today, a physician, especially a general practitioner under the network of a HMO, has limited time for a constant product update. I am not disputing that each physician should keep abreast of any new drugs launched, and our internet-delivery system can make such attempt an easy task. However, physician's continued learning can always be enhanced in a one-on-one “tutoring” session, when a drug representative visits. Due to complexity of new products, drug representatives could play an important role to disseminate results of this post marketing studies. It is also likely that through these calls, some of the beneficial drugs which are under-prescribed can be brought to the physicians’ attention. I believe such relationships can be beneficial to new drug developments. Many of the drugs currently on the market simply would not exist if it were not for such close relationships whereby physicians enroll patients in manufacturer’s clinical trials, and provide valuable advice on the drug development. Some think that such marketing call may result in a physician giving preferential treatment to the drug which the visiting drug representative promotes. In reality, and in our intense competitive environment, physicians do see other representatives from the other manufactures. Competition among manufactures itself will offset the effect exerted by the other drug representatives. Further physician’s prescriptions could be subject to the insurance company’s approval. An insurance company may request that the dispensing pharmacy to substitute a branded drug with a generic one whenever it is available. I do not see how giving physicians drug samples is an issue, since the samples are not for sale. Some physicians may use free drug samples to help low-income or uninsured patients, especially if the sample is of a new, expensive drug, which would treat patient’s condition. While the influence of the freebies on physician's behavior is real, it is limited.

The health care community is doing a good job in constantly bringing this freebie issue alive for discussion. This is part of the effort in keeping the powerful drug companies in line with certain standard of ethics. Within the professional body, in limiting the undue inference, the American Medical Association has recommended physicians not to accept gifts over $100. The industry has always been working toward upgrading a set of codes of conduct. Even Congress, which is thought to be heavily influenced by lobbyists from big drug companies, introduced legislation last fall to make drug companies disclose how much they have spent on gifts to medical practitioners. For now, we may rely on people like Cynthia Fitzgerald (as pictured above) in the health care community to be a willing whistle blower as another form of deterrence. With all these efforts acting collectively, and despite all the happenings and discussions, I do not feel we have a fractured trust that will end our health care reform hope.