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.

Your private health information: Could it end up on YouTube?

Ok, imagine this.

You take a video of your little girl's soccer practice with your iPhone. Within moments it's posted on YouTube for the grandparents to see.

Minutes later search engines called spiders begin to crawl across the data set of images on your upload. Face recognition technology identifies a face on the video and, with some assistance from the geo-tagging of the built in GPS metadata that accompanied the upload, gets a general location of where the video was made.

It determines that your child has other photos posted on Flickr and also a photo in the local newspaper. Now it associates a name with the face. The name might be associated with a Facebook account.

Maybe there's an article that mentions a parent. The data discovery evolution continues continually attributing identifying information. The parent's information is exhaustive, but most importantly it contains an address.

From a face on a cell phone video, a sexual predator might discover the home and contact information for your child.

All searchable by keyword: soccer, girl, Facebook, my home town.

Scary.

Its easy to see the danger the internet can pose to children. We all know that. From Net Nanny to Web Watcher there are software and web packages that purport to protect our children.

They are good. But not perfect.

Health information interconnectivity is considered the holy grail of disease management.

In fact, most experts, including me, feel that without a robust means of health care providers sharing information we can never achieve the cost and quality metrics required for optimal health care delivery.

Especially as we enter the world of the ACO - accountable care organizations - where multiple providers may very well be paid to manage the health care of an individual patient, it will be essential to share information.

Cost savings will be dependent on reducing duplicated tests, encouraging patients to fill needed prescriptions for their diabetes or hypertension, or reminding and scheduling patients for preventative health measures like mammograms or a colonoscopy.

And patients will like it.

Can you imagine a doctor visit for an elderly patient where medicines are continually updated including whether they were even filled at the pharmacy?

We have that now in our office and many physicians subscribe to pharmacy data information that can help us know what medications patients are using.

In addition many offices and emergency rooms have access to claims data for some insured patients.

What does this tell you? Well, for one thing, it can report what you have filed on your health insurance as a recent claim including diagnosis codes for illnesses, visits to other emergency rooms or health providers, and procedures you may have had.

It certainly isn't perfect - the coding has to be right and it's stale (often not being updated for months) - but it provides a snapshot of the health care services that you received which in a pinch can provide a physician with some idea of your medical background.

Some insurers will also report medical allergies to round out the picture.

But the problem here is that all the information is fragmented. There are multiple sources, many that are not up-to-date or recent, and they are on many different databases.

The word thrown out a lot by governments and policy gurus is "data warehousing." This would be a central repository of all the available information that could be accessed securely and updated.

The benefits could be great: better managed health care for individuals and populations. Maybe less visits to the emergency rooms for diabetics, fewer readmissions to the hospital for patients with congestive heart failure, and less unnecessary tests for patients with chronic diseases.

The concept of disease case management might be able to lower cost and improve quality. A value statement that would be hard for anyone to argue with.

But are our privacy rules robust enough to protect our patients?

That's really the question.

So imagine these scenarios.

A school district during a new hire review of a teacher discover that she's taken antidepressants in the past. Would this be a good employee to hire?

A drug company does a database query for men with erectile dysfunction as a diagnosis code and who have been prescribed Viagra. They are sent emails and junk mail advertising a new little blue pill.

Your company hires a consultant to lower health insurance costs for your employees. They sell a product that searches the web and ranks future applicants on past health care costs and usage and provides a score. With a high score an applicant doesn't get an interview.

You file a disability claim on your short term disability plan. Your insurance company, by finding your face on a YouTube video and attributing a name, sees that you can play on a YMCA flag football team. See the problem here?

You could write hundreds of these scenarios. Does it mean that we have to shut down interconnectivity and data sharing of sensitive health information?

No. We can't afford too.

We must continue to move the ball forward to achieve quality and cost improvement.

We have no other option.

But it does raise the concern that as we get more and more data on the web, and more and more sophisticated in our processing power, there will be big problems with patient's privacy.

The best thing that could happen would be a systematic process -- where everyone works together -- to create a unified secure database with strong patient protection rules, including who can access the data and how it can be used.

For now we are left with a fragmented system where companies and governments are creating their own plan and their own data warehouses. All of these will have their own rules, security, data, and problems.

So am I scared of posting something on Facebook?

Absolutely not.

Do I think someday someone will be posting the status of my high blood pressure?

Absolutely.



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Location:Dallas, Texas