What my children will never see? Things disappearing from the doctor's office

On a recent trip to Austin I flipped through the worn copy of Spirit magazine in the seat back of a Southwest Airlines 737 and saw this nice article about babies -- and specifically what they see and understand very early in life.

I love my two young kids, and although they both aren't as young as they used to be (neither am I), I love to share with them new experiences, sights, and the general joys of life.

I think all parents must feel the same way.  There is just something about seeing the the glint of newness and understanding in the small eyes of a child.  

But today I began to wonder about things our children will never see, particularly related to health care. We have on our own list from when we were growing up, but it's certainly different now.

From polio, mumps, and small pox:  thankfully they are all distant memories.  As a dermatologist I do get to see some of the unusual but still rather rare diseases (measles, for instant) that I heard about in my childhood.

But children today will miss out on many things that are common place in our day to day lives.

Here's my list (feel free to add or subtract in the comment box below):

1) Marcus Welby:  hometown physicians in private practice that take care of families for decades will be a thing of the past.  I've written about my good friend John Keller, MD, a family physician in the small rural town of Fairfield,  Texas before here.  Practicing for over 50 years in one place, he will probably be the last "Marcus Welby" doctor that I know.  And my children will never see that.  Only on re-runs. 

2) Chicken Pox:  childhood vaccination makes this common disorder now very rare.  And, if we're lucky, shingles or herpes zoster will also be a painful encounter our kids will not have to endure.

3) Rectal thermometers:  I'm sure someone will comment that these are still around.  The last time my kids were sick it seemed like someone just shot their head with a laser thermometer -- nurses don't even have to touch the patient any more.  Novel idea.

4) White hats:  speaking of nurses -- what about those white hats?  I mention them occasionally and finally someone in my office told me that she wasn't sure it was politically correct to talk about them anymore.  I'm not sure I understand that, but I've changed my workplace banter after their expressed concern.

5) Prescription pads:  Ok, I know this is maybe a tad progressive.  But in our  paperless office we don't write prescriptions by hand any more.  We send everything electronically using an e-prescribing application.  And, frankly, everyone loves it including my staff, patients, and finally me. I know there are some slow adopters out there, but Medicare and other insurance carriers will drive that train.  Paper prescription pads? They'll be gone.

6) Drug company pens:  Yes, the pharmaceutical company give aways (not just pens: but dummy plastic models of the skin, Post It notes, stethoscope labels, you name it) are all gone.  No longer will kids see a Viagra pen or a Lipitor flashlight.  New pharma rules prohibit these types of "inducements" because some bureaucrat thinks that supplying a pen will induce the doctor to use that pen to write an expensive prescription.  Personally, I think this is stupid.  Maybe doctors shouldn't be taken on golf junkets or expensive dinners...but a pen.  Really.

7) Ties:  Though not mainstream, health care workers are quickly adopting the casual Friday look in the medical office and the hospital room.  Why?  Well those ties were shown to carry germs.  So scrubs and casual shirts are now considered appropriate dress code for health care workers.  

8) The Co-Pay:  Well, it's not gone yet, but more and more insurance products are "high deductible" health plans.  It used to be that patients could pay $20 and get all the health care they could milk out of a 15 minute visit.  Those days are disappearing as the most popular insurance product sold in our home state last year was one with a $3000 deductible.  Patients and physicians are now more cautious in their health care decisions.  That's a good thing.  The bad news is that every care component falls directly to the bottom line.  

Feel free to add or subtract from this list.  Hopefully there will be exciting improvements in our health care delivery system, new drugs to treat disease, and exciting technologies to cure our ailments that replace the items on the list.  

We can always hope.

- Posted using BlogPress from my iPad

Groupon: Are coupons really the right answer for health care?

I'm always fascinated by new technology and particularly ways social media works in our world.

So it was natural for me to sign up for Groupon.com, the internet based deal program that works with local vendors to offer special coupons and discounts for products or services.

Sometimes these deals are just incredible - from 50% off food products to half price golf to yoga for $19 per month rather than $140.

But what about using coupons for health care services?

Sounds odd, I know, but this has been a common practice for years with aesthetic services and cosmetic procedures or treatments.

It's not uncommon at all to see deals for "free Botox" or discounts on micro-dermabrasion or chemical peels.

But would you be influenced by a coupon for "free prostate exam" or "buy one get one free mammogram"?  Or would you just think that provider was weird?

It may sounds strange, but actually this happens every day.

It's hidden behind the cloak and dagger world of the pharmaceutical sample closet.

For years the drug sample has been the easiest tease to entice patients to try a different medication.  Sometimes they are very helpful -- a difficult medication to use (like an unusual dispenser for a spray on product), unusual side effects ("try it before you buy it"), or most commonly the patient has no money and they leave with a bag full of free drugs.

But these are certainly short term solutions and may or may not lead to a patient actually buying the product.

It's no surprise that most of the samples in the closet are for chronic medications -- not for something you have to take for a week or less.

But the interesting invasion into the sample closet has been the coupon.

Now not quite "groupon-like," coupons are now available for almost all name brand, non-generic medications -- particularly if they are early in their evolution of release.

This is how it usually works:  you decide you want to prescribe a new anti-hypertensive (an expensive way to say blood pressure medication).  Compared to a generic medicine which might fall under the $4 per month Walmart plan, this medication might be $300 per month.

But, there might be some advantages:  lower incidence of side effects, easier dosing regimen, or maybe its more effective.  There usually is a real medical reason despite what some Washington pundits might say.

Newer drugs usually work better.

But, nevertheless it costs $300. That's roughly half of some people's Social Security check.

Now with insurance this medication would be a lot cheaper (for the patient) but it is very likely that it would not fall under the "preferred plan" of their prescription drug coverage.

That means that it would likely cause a higher co-pay such as $50 as opposed to $5.

This is where the pharmaceutical coupons come into play.  Now, instead of advertisement laden boxes of pills, the sample closet is full of boxes full of coupons or discount cards.

Patients are asked to call a 1-800 number to activate the card, "register" (which means the company collects information on the patient, disease, and provider), and then the card can be used to off set part of the extra cost related to use of the expensive medication.

These cards usually function as "discount cards."  That is, they will provide either a certain reduction in your copay amount, or they will fix the total cost of medication at a certain point.

Most of the cards require you have insurance to use them.  There is no free lunch here, and the drug companies themselves don't want to be out the total cost of the drug, only part of their margin.

Sometimes there are limits on the amount of benefit you can receive.  The card may only be good for three refills, or it may be unlimited.  You want to make sure you check this carefully before you continue to refill your medication.

Pharmacies as rule don't like to deal with these cards.  Much like grocery stores don't like to deal with coupons.

There is an extra step for them, possibly some activation required on their part and certainly they have to carry additional float, in addition to your insurance, before they will get paid.

What's fascinating to me is that these provide a direct incentive to use a more expensive medication.

Now, as I've outlined here, there are some benefits of these cards.  But let's face it, these are expensive medications -- there is no free lunch.

It's the incentive that seems bizarre.  Physicians and hospitals are forbidden from discounting co-pays, not collecting deductibles, or for offering covered services for less than the contracted amount in most insurance contracts.

There have been several lawsuits already between rival health care systems in communities where one hospital might write off co-pays or deductibles to entice patients to choose their facility over the competitor.

This might be like a patient knowing that regardless if he has Blue Cross Blue Shield insurance, for example, they could choose either emergency room -- because the cost would be the same to them.

Patients with high deductible insurance plans are particularly susceptible to this type of gaming.  The catch is that the hospital is able to collect enough money on the subsequent procedure or test to offset the loss of the deductible.

The problem is for the insurance company and the other insured patients that are on the policy.

It removes the incentive to stay within network and comply with the contract that makes indemnity insurance work in the first place.

Everyone has to play by the same rules.

So why do pharmaceutical companies get to use these discount cards?

I'm not sure I can answer that question, but I hope I've been able to shed some light on these type of cards and discounts.

In some situations they may be very helpful.  If you require an expensive medication, particularly one that is new, be sure to ask your physician if the company offers any type of discount card.

If not, then asked them for a lower priced, generic alternative.

Otherwise, just be aware that these cards can get you established on an expensive medicine for you only to find out that the benefits were temporary.

Also be careful if the company is going to send you a rebate.  This puts the risk on you for collecting the money.

So although not quite Groupon.com type coupons, there are some discounts available for expensive medications.

You just may have to shop around and be an educated consumer-patient.