America, Love It or Heal It

A blog about health, health care, and health care reform

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Addictions in the primary care office

As with any disease, prevalence of this narcotics abuse is region-specific; an hour north of the office where I practice, Rio Arriba County in New Mexico is home to one of the highest opioid overdose rates in America – up to five times higher than the national average.  Our patients routinely lose family to addictions; our clinic has been home to a near-fatal overdose within the walls of the facility.

Addictions treatment has always orbited the periphery of mainstream medicine, and the recovery community has traditionally been averse to medical intervention for what was historically considered a condition of weak will, most amenable to talk therapy and group support.  With the advent of supported sobriety medications like buprenorphine for opioid dependence and naltrexone for alcohol cravings, addictions treatment has shifted  sharply toward a medicalized model.  But with an estimated 23 million Americans needing help with addictions (2 million of those dependent on opioids alone) and a few thousand addiction specialists across a number of specialties (the exact number is difficult to estimate, as the American Board of Medical Specialties does not recognize an addictions medicine specialty outside of psychiatry), the numbers simply do not add up: too many patients, too few specialists.  The result is that patients are simply not offered straightforward, life-saving medicine.  An appropriate analogy is a situation in which all diabetics are denied treatment unless they locate themselves an amenable endocrinologist.

The only specialty with a front-lines army legion enough to provide for this population is primary care.  But primary care has been remiss in stepping up to its responsibility for this routine condition.  Some offices feel they lack resources to address high-needs populations; some offices do not wish to attract such patients, politely ignoring that few clinics do not already count such patients among their loyal rosters.  Ironically, addictions treatment is not a difficult area of medicine to learn anew; still in its infancy, there are only a handful of drugs in limited regimens to effect change in addicted patients – making this field far less complex than, say, metabolic syndrome. An addicted patient should be able to walk into any primary care clinic in America and receive standard-of-care treatment on site – just as they would for hypertension or diabetes.

As long as addictions are marked as a condition to avoid and disdain, critical masses of providers needed to battle back the tide of narcotics abuse will not emerge.  Primary care must become the locus of outpatient treatment, with inpatient and/or specialty treatment reserved for the most ill or incorrigible cases.  Primary care training centers must teach evidence-based use of supported sobriety medications; states can support such resources by offering tax breaks to practices that provide rare services, as is currently proposed in New Mexico.

Addicts in recovery are a uniquely rewarding population – I can think of no other disease whose sufferers beg for their place among woefully inadequate programs, and profusely thank me for helping them wrest their lives back from the abyss of a difficult existence and early mortality.  These patients already haunt the halls of just about every clinic in the nation, quietly seeking help for a dependence that they may or may not admit to their physician.  Whether in high-prevalence crisis zones like northern New Mexico or in areas of average abuse, primary care owes it to our patients and our profession to face down this epidemic, to meet the challenges of our time.

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A brief side note

Recently two friends and I were mulling over some of our more taxing workplace interactions and finding common struggles in our most difficult patients: those suffering from addictions, uncontrolled pain, and the overlapping arena between the two.  Out of this discussion came the notion of opening up a discussion forum for practitioners and the general public looking to find innovative solutions to the problems at hand.  This forum - tentatively under the name Opioid, Addictions, and Pain Innovations Network (OAPIN) - is now up and running in a skeleton framework on Facebook.  Drop on by and visit - any and all contributions and discussions are welcome. 

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Our daily neuroses and occasional psychoses

The dust had hardly settled on the Sandy Hook elementary school when the most futile of all debates began: is the lack of mental health infrastructure at fault for Sandy Hook, or are the mentally being unfairly blamed for violence? Both positions are both right, and they are both wrong.  Mostly, it’s a matter of definition: what does it take to define someone as “mentally ill”?

If you read the bible of the fine folks over at the American Psychiatric Association - the Diagnostic and Statistical Manual (DSM-4) - you will find that depression, schizophrenia, and a variety of other wide-cast diagnoses fit into one category (“axis I”), while mental retardation and personality disorders are kicked over into another category (“axis II”).  There is little biological evidence (or even sociologic evidence) for these categories. Indeed, I think that rightly-maligned Sigmund Freud invented a better paradigm back in the day when he separated the “neurotic” (those with routine disturbances that interfere with everyday life) and the “psychotic” (those entirely and dramatically disconnected from reality).  

The mantra “The mentally ill are not violent” belies a few unfounded statistical presumptions.  We presume that probability predicts individual behavior on a one-to-one basis – that is, if mentally ill people are more likely to be victims than perpetrators, that mentally ill people are never perpetrators of violence.  This is not true, either statistically or factually.  We also presume that we have included all diagnoses in this statistic; unfortunately, anti-social personality disorder (sometimes known as “sociopathy” or “psychopathy”) accounts for a disproportionate number of folks taking up space in our jails for violent crimes, but is an axis II diagnosis - if you include this as a mental illness, that assertion that mentally ill people are not violent becomes false almost from the outset.  Most importantly though, there is the very important fact that no matter what the diagnosis, in general we all agree that what was happening in the heads of people like Jared Loughner, Seung-Hui Cho, and Adam Lanza when they chose their climactic acts was not within the realm of what the general public is going to call “normal.”  Something was off.  Something was saddened, something was angered, something was vengeful, maybe something was delusional, but something was off.

Often, circular reasoning is employed to then declare these perpetrators to be mentally ill.  In one manner, this circular reasoning is an offense against science and common sense.  But we still have to address the idea that the mind-set of these perpetrators was outside of the norm, outside of what I decided to do when I got up out of bed this morning, outside of what you thought was the best course of action last time you were red with anger at another person, outside of what any but the rarest individuals are going to find acceptable.  What we have to address is that every one of these killers – the Columbine shooters, the Aurora shooter, the Virginia Tech shooter, and now Adam Lanza – was in a very bad head space.  This place may have been schizophrenia, this place may have been mania, this place may have been any number of zones housed under Freud’s umbrella of “psychosis.” Or this place may have been the fascination of sociopathy or psychopathy - that shadowy realm of people who lack the brain parts that install conscience, social anxiety consequent to bad behaviors, and compassion in the rest of us. Or this place may have been so much more mundane: without hallucination, without delusion, without a manic rush, without anything much more dramatic than what Freud would have called “neurosis.”   This is the province of excessive anxiety, of excessive anger, of depression, of hopelessness, of revenge and remorse, of distorted senses of self and justice.  These are much harder to diagnose – what is the DSM-4 criteria for “hopelessness brought on by years of bullying”? or “unbridled anger at being turned down by every woman ever, even it it’s because you were creeping them out?”  There is no mass shooter who does not turn up some kind of emotional landscape of motivation (indeed, because there is no human action that exists outside of its emotional context).  What is so disturbing is that so many of the motivations are not inside the comforting world of “crazy;” they fall decidedly into the non-comforting world of the very distraught, but entirely sane.  That which Freud would have called neurotic.

This is why the mental health advocates are so very right, and so very wrong: because the instinct to blame violence on psychosis is so righteously inaccurate, and so very prone to stigmatizing and marginalizing people who are more often victims than perpetrators of violence.  And because, simultaneously, the need to treat mental unwellness is key to preventing these kinds of tragedies.  But we have to consider “mentally unwell” not as the minority of psychotics (or the super-minority of psychopaths), but in the majority of neurotics.  Neurosis – that’s most of us on a very bad day.  That’s the anxiety that makes teenagers cut themselves just for the sharp twinge of relief.  That’s the anger that makes people punch walls, or their wives.  That’s the depressive tendency that makes it just kinda hard for some people to get out of bed some days.  This stuff is insufferably common, even boring, but it is the stuff of mental unwellness on a scale that dwarfs manic episodes, psychotic depressions, and schizophrenic delusions. It’s you and me, on the bare edge of our roughest times, with just a touch more explosiveness than most of us can hammer together.  But it probably explains more modern massacres than either frank psychosis or frank sociopathy.  

This demilitarized zone between psychosis and neurosis is where the hard work of general mental health begins.  It begins with coming to grips with the idea that mental illness is not limited to the obvious – it includes the states of mind that are simply unwell, unwell enough to cause harm.  This territory traverses some entirely unsavory phenomena – developing anger management techniques for men who threaten their partners, or addressing the understated white male rage that seems to underpin so many of these shootings.  It ends with the place where we started: that psychosis does not in and of itself predispose one to violence, but that the gamut of Freudian psychosis, neurosis, and straight-up psychopathy does appear in just about every act of mass violence we know.  We can start with the idea that the mentally ill are not necessarily violent, and end with the idea that some kind of mental unwellness underlies – by that circular definition that people who shoot children are necessarily not within the norms of mental status that we accept – nearly every episode of mass violence.  Without these two contradictory notions coexisting in real time, we will forever bicker about whether the mentally ill are at fault or not, when the real question is not about fault, but how to support and nurture mental wellness in all the myriad of forms it can take. Without understanding the breadth of the problem, we have no hope of ever preventing its consequences.

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Prescription narcotics crackdowns and the law of obvious consequences

With prescription narcotics abuse reaching epidemic levels across the United States, federal and state authorities are struggling to reign in opioid addiction.  The narcotics crisis was cross-bred accidentally from good intent - the push to make pain the “fifth vital sign” - and extremely poor foresight, as physicians were mandated to treat pain without increased training in appropriate prescribing or management of adverse effects like addictions.  Now with a rush to reverse skyrocketing addiction and overdoses, we risk another wave of obvious consequences: as the supply of opioid pain pills dries up, those already addicted to pills are likely to turn to a cheaper more plentiful narcotic - heroin.  In turn, the pressure to transition from pills to injected heroin can only result in an an infectious disease explosion among a population already squeezed to the margins.

Now more than ever, narcotics treatment programs are critical to prevent pill addicts from turning to injectable opioids. However, inherent flaws limit classical narcotic treatment models.  Traditional treatment removes individuals from house and home to centralized live-in facilities, advising that they discharge to a new town with new friends to minimize the chance of relapsing into old behavior patterns; this works well for the globally mobile, but fails in the provincial backwaters of America where the old urban drug centers are relocating these days, and where those in recovery may have never before lived more than a few miles from the place they were born.  Old models see quitting addiction as a singular opportunity, and relapse as moral failing; we now appreciate the strong physical component of addiction and the normative cycles of quitting and relapse - cycles that do not lend themselves to repeated bank-breaking stays at expensive inpatient retreats.  Moreover, the outdated perception of drug addiction as an affliction of the urban, dislocated, and homeless has long ceased to tell an accurate story: addiction today is an increasingly suburban and rural phenomenon.  Overdoses are no longer back-alley, anonymous affairs – they are likely to happen in livingrooms and bedrooms, with extended family nearby, witnessed by children, guaranteeing the cyclical trauma of calls to 911, flashing sirens of police and ambulance carriers at the front door, child protective services coming to retrieve siblings and cousins and breeding innate mistrust of authority.  Drug deaths often afflict breadwinners and heads-of-household, and morbidity and mortality among this demographic compounds intergenerational poverty that drives futures of hopelessness and addiction.

These evolving dynamics of addiction place outpatient opioid replacement medications like buprenorphine (branded under the names Suboxone and Subutex) at the forefront of treatment. Designed to kill the sheet-drenching terrors of opioid withdrawal and the siren call of continual cravings, buprenorphine allows narcotics addicts to return to work, school, families, and the business of living life without prolonged interruptions for relapses and treatment.  Ironically, prescribing buprenophine requires extra training, a special DEA waiver and programmatic oversight, and is not permitted by mid-level providers such as physician assistants - restrictions that are draconian compared to the minimal requirements needed for medical providers to write unlimited quantities of narcotics. To successfully head off a secondary public health crisis from the crackdown on pill users, outpatient narcotics treatment must become a routine part of every primary care practice - with minimal barriers to start-up, training in every primary care residency across the country, and support rather than the current intrusive oversight on already extant buprenorphine providers.

If the coming crackdown on safer prescription narcotics is not accompanied by a move toward mass treatment of opioid dependence, the consequences are predictable and inevitable: a mass transition from pills to heroin as the pill supply dries up, accompanied by an explosion of avoidable infectious diseases - HIV and hepatitis C, MRSA abscesses and other routine superficial infections, and the rarer bogeymen of heart valve infections, bone infections, and “flesh-eating bacteria” that particularly afflict those desperate enough to put contaminated needles under their own skin. The social and financial cost of these acute and chronic conditions will haunt our national health well past the rash decisions made on narcotics policy today.  At this critical policy juncture - with pressure on all side to stem the flow of manufactured narcotic pills - now is the time to throw open the floodgates on cost-effective, evidence-based narcotics treatment.  Most of all, addiction must be understood as the complex medical and psychological condition that it is - leaving behind forever the notion of addiction as moral weakness to be scorned, and finding the common ground to meet those in the throes of addiction on their own terrain. 

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The Limits of Customer Service in the Exam Room

Under the heading of “Value-Based Purchasing,” Obama’s Accountable Care Act includes measures to link hospital reimbursement to patient satisfaction measures.  Through both public and private insurers, this trend is likely to spill over into the outpatient setting in the very near future.  

Aside from creating redundancy in the market (with some very rural exceptions, patients can act as agents of their own satisfaction by voting with their feet), there are serious limits to physicians as agents of pure customer service.  Our roles supercede service to sole patient sitting on the exam table, and attaching payment to patient evaluation endangers the complex responsibilities that physicians - especially primary care providers - owe to the community at large.

As primary care physicians, we are charged with negotiating sensitive and intimate health concerns.  Control of elevated weight and blood sugars that patients would prefer to ignore, a dogged preference for menopausal hormonal regimens that evidence is mounting against: we handle a myriad of difficult topics with the best aplomb we can muster, but these discussions are not always met with open arms.

We guard the continued utility of antibiotics beyond this generation’s coughs and colds.  In refusing a Z-pack for viral illnesses, we may be engaging best practices, but we rarely leave a happy patient who expected an anti-bacterial cure for their viral sniffles.

We have become the standard-bearers for government’s well-reasoned but burdensome push to bring health care informatics into the twenty-first century.  Health care has fallen decades behind information technology; the well-intentioned rush to establish technology standards through criteria like meaningful use, patient-centered medical home, and e-prescribing cuts into the time we would like to spend talking to patients about patient concerns. 

We are the sentinel in the battle against a growing national addiction to narcotic pain medication.  Deciding when to write another script for Vicodin and when to transition to non-narcotic modalities is an art that takes both training and courage, but with an epidemic-sized population hovering on the edge (or already over the abyss) of addiction, few patients are satisfied when a request for opioids is denied.

We are the unwitting actuaries of the health care budget. We are torn between the newest, most heavily marketed drugs and apparati, and the driving push to curtail spiraling costs: to employ the cheapest evidence-based medications, to grudgingly abide by insurance company prior authorizations, to realize that sometimes the most expeditious answer also places the most burden on the health care dollars that we all rely on as the bulge of the baby boom generation passes through the snake’s belly.  

Moreover, outpatient physicians choose who we care for.  Under reimbursement schemes that punish providers for problematic interactions, the most likely outcome is that problematic patients will find it difficult to retain medical homes outside the home of last resort: the emergency department.  We all know these patients - chronic narcotic seekers, unstable psychiatric patients, those who inhabit the nebulous borderlands between volitional bad behavior and true mental illness.  Maintaining equanimity in the office in the presence of such patients requires subtle skills such as setting boundaries, establishing protocols and limitations, negotiating the news that needs will be met but impulses and whims will not be indulged.  The physicians most willing to take on such patients should not be doubly punished for the ruckus that frequently arises around them - they should be afforded the additional resources it takes to stabilize such individuals and minimize their disproportionate impact on the hospital system.

Linking reimbursement to patient satisfaction hobbles physicians’ ability to uphold high standards and to broach difficult terrain when necessary.  Applied with a broad brush, tying reimbursement to patient satisfaction harbors the potential to interrupt the integrity of the doctor-patient relationship and compromise the larger promise made by physicians to uphold the health of the nation. 

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Avastin: The Pursuit of Last False Hopes, Extinguished

In the past month, the Food and Drug Administration yanked its formal stamp of approval on Avastin – a chemotherapy drug designed to starve tumors of their blood supply – for the advanced stages of breast cancer. Because the drug still carries approval for other indications (especially late-stage colon cancer), patients can still obtain the drug by prescription for off-label use. But because it will lack formal indications for breast cancer, insurers are highly unlikely to continue paying for it. And at an estimated $100,000 per year for sustained use, Avastin is one of the most expensive drugs ever to hit the pharmaceutical market; it is very unlikely that few if any breast cancer patients will be paying for it on their own.

The outcry was immediate and predictable. Breast cancer advocates of some stripes decried the decision as a crime against women’s health – a travesty against hope. The opposition notes that the costs come with desperately little proven benefit, and that the drain on health care resource might go to uses that better suit both breast cancer patients and others who desperately need a slice of the health care pie. (A notably contrary voice in the debate has been the always-stalwart Breast Cancer Action, which applauded the FDA for revoking approval of Avastin, and implored the FDA to “uphold stringent drug approval standards over hasty access without legitimate clinical benefit”). Either way, one can bet the FDA did not tackle this bombshell topic lightly.

On the technical side, the FDA’s role is to protect and promote health, and they may be doing just that by revoking this specific indication for Avastin: in defense of women’s health, the risks of Avastin – risks like heart failure, internal hemorrhage, and intestinal perforation – come with little to no extension of life in the face of metastatic disease.

On the political side, the enemy of Avastin access is not necessarily the FDA: the FDA did not remove access to Avastin – the functional result of the decision was simply that Avastin will likely not be paid for by insurance because it no longer has an official indication for breast cancer specifically. (Off-label prescribing is allowed for most medications on the market with some rare exceptions – as long as a medications is FDA-approved, doctors can prescribe it for just about any indication, though insurance is less likely to cover expensive medications for unapproved uses.) If the medication were reasonably priced, this would not be an issue; instead, continuous use of the medication costs more than a mortgage on a split-level two-car garage house in most midwestern cities. But there is little outcry against Roche/Genentech, the makers of the drug, for their outrageous price gouging – an implicit collusion between the activist voice and the profit-makers that suspiciously mimics the dynamic between a hostage-taker and the sufferer of an obtuse form of Stockholm syndrome. While breast cancer activism has largely aimed its wrath at the FDA, few outside of Breast Cancer Action have squared off against Roche/Genentech for their rapacious pricing scheme that truly forms the barrier between patients and last-ditch use of the drug.

Avastin is not the first or last drug to land in the middle of such controversy over end-of-life access to drugs with potentially sweeping effects on both disease and remaining normal tissue. The compassionate use movement did not start with antiretroviral drugs – the revolutionary compounds developed in the early 1990s to combat AIDS – but that’s where the move to expedite trials and allow dying adults the right to off-label use outside of regulated trials got a foothold. And perhaps rightly so: during the worst of the AIDS epidemic, the rapid mortality rate far outstripped the ability of formal trials to absorb the number of people who could benefit from them – people who had nothing at all to lose. There is likely no way now to know for sure now, but some AIDS patients probably died faster from unproven and ultimately harmful experimental drugs. Some got the miracles they sought, miracles that are now go by routine names like nevirapine and abacavir, Combivir and Kaletra. This is the legacy that Avastin was born into when it was approved in 2004, and this is the environment that Roche/Genentech banks on when it faces down the FDA with a cadre of its own medico-legal experts backed by an army of breast cancer patients and family girded to fight the battle for a drug that annual nets the pharmaceutical conglomerate some several billion dollars – a sum that will take a large hit in the wake of the FDA’s recent decision. (Bizarrely, one line of this activism invokes a strain of libertarian reasoning that is equally circular as it is paranoid: that Avastin’s revocation by the FDA as a secret victory for ObamaCare socialist cost-control measures – in the same sentence decrying that Medicare will no longer cover the drug without FDA coverage, without ever wondering why Avastin costs so damn much in the first place. Government hands off my Medicare? Indeed.)

So to answer to the real root of whether Avastin should be available to women with stage-four breast cancer – whether the FDA was acting in the best interest of women at large and women with this horrific disease in particular – one also must now ask some tough questions beyond evidence and cost-effectiveness: Is it enough to rely on the internal narrative of the breast cancer patient – the first-person ethnographic voice that drives much of activism in the internet age – when this narrative may conflict openly with medical evidence? Can we rely on patient self-advocacy, when that patient self-advocacy movement had been so intentionally and powerfully tainted by the pharmaceutical manufacturers whose profits rely on the very lucrative and politically powerful business of breast cancer activism?

Every terminally ill person dreams of this age of miracles that AIDS sufferers received in the 1990s – a last-minute Lazarus reprieve that stays the executioner’s bell of their disease. Every pharmaceutical company knows this, and none have shown any moral restraint in invoking this sentiment and this desperation to their advantage, while twisting the knife of a substantial price tag into the backs of sick and dying consumers. As profit-generating entities, this is, after all, their raison d’etre. Pharmaceutical companies are like your distant acquaintance that shows up with supper when you’re sick, only to seduce your husband behind your back: they appear with cheery illusions of comfort. But they are not your friend.

Reasonable solutions are possible, but are unlikely to be invoked. Roche/Genentech could provide the few breast cancer patients who have actually responded to Avastin with supplies of the drug at cost – a true invocation of the phrase “compassionate use” – until this generation of patients fades out; with over a billion dollars a year in profits, this isn’t an unreasonable request. Insurers could also look at these few with some exception in mind. Moreover, research needs to be done (and probably already is) to understand and ultimately predict those exceptional Avastin responders – much as we understand why some breast cancers respond to tamoxifen and Herceptin, and others do not – and tailor chemotherapy regimens specifically for use specifically for people most likely to benefit from Avastin.

Until then, however, the FDA decision stands. Will the decision ultimately save or harm the lives of women with end-stage breast cancer? That remains to be seen.

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Cheaper generic medications: Not coming to a pharmacy near you

The New York Times reported Friday on a move by Pfizer – the makers of the blockbuster cholesterol drug Lipitor – to manipulate the market to limit generic supplies to a number a major drug management agencies after Lipitor goes generic in the coming months:

“Pfizer has agreed to large discounts for benefit managers that block the use of generic versions of Lipitor, according to a letter from Catalyst Rx, a benefit manager for 18 million people in the United States. The letters have not previously been made public. A pharmacy group and an independent expert say the tactic will benefit Pfizer and benefit managers at the expense of employers and taxpayers, who may end up paying more than they should for the drug.” [emphasis mine]

Lipitor is said to be one of the most profitable drugs ever produced, generating over $100 billion in sales and forming a mainstay of Pfizer’s drug portfolio. And this is not necessary bad; Lipitor saves lives. It plays a role in primary prevention of cardiovascular disease, it can be the difference between rehabilitation after a heart attack or stroke and rapid recurrence leading to greater debility or death. It is not without problems, but overall, it is an important drug in the modern arsenal against chronic disease.

But there are a couple complications to this picture.

One is that in the world of the statin drug class to which Lipitor belongs, not everyone with high cholesterol needs Lipitor – or, more importantly, a medication as expensive as Lipitor. There are half a dozen other drugs in the same class, several of which went generic so long ago that they appear on the Walmart list of $4-per-month medications. The older generic statins are notably weaker; this isn’t a secret. But for your average middle-aged person walking around with high cholesterol – those who eat a little too much butter, exercise a little too little, or just drew the genetic short straw on the lipid metabolism front – the cheap medications will effectively get the cholesterol numbers to where they need to be (so too often will diet, exercise, and some other non-medicinal approaches, but let’s set those aside for a moment for the sake of argument). The truly more potent (and notably more effective, and notably more expensive) statins – that is, Lipitor and Crestor – can generally be reserved for people with true disease in whom there has been a failure to get to goal cholesterol levels with weaker medications: people with prior heart attacks and strokes, people with familial cholesterol running sky-high numbers for no good reason, people who have undergone surgery to actually remove cholesterol plaques from their arteries.

But that’s actually kind of a small market compared to the millions and millions of essentially healthy 50ish folks who could head off problems in the future with a little help from a statin friend – ie, those who will probably do fine on a generic drug. So why is Lipitor such a blockbuster when the number of people who need it relatively small?

That, of course, comes down to marketing. Pfizer has long advertised the potency of Lipitor – and wouldn’t you want the best for your heart? – failing to note that cost-per-cost, the best just isn’t necessary for many people. Samples given through doctor’s offices (which are invariably branded drugs, never generics) instill brand loyalty from the side of both the doctor and patient. Moreover, pharmaceutical companies skew or hide the true cost of these upper-echelon drugs by marketing schemes like copayment vouchers that reduce the cost to the insured consumer for branded drugs from higher cost (where they should be) to zero – encouraging patients to request more expensive drugs than are necessary because the up-front cost to themselves is so low.

But true market manipulation on the scale described – that is, using the clout of a major manufacturer to block the early sales of generics – is a dangerous and costly precedent. This process is enabled by the streamlining of drugs through “pharmacy benefit managers” such as Medco, which you might have encountered as one of the “mail-in” pharmacies that more and more insurance carriers are requiring patients to utilize. However, the unspoken secret of these “mail-in” pharmacies is that many of the discount brick-and-mortar pharmacy chains carry generic medications at a fraction of the price of the mail-in servicers – sometimes at prices less than a standard generic copay for an insured patient. Insured patients are made to feel that they are compelled to use these monopolizing benefits managers, when in fact consumers are only required to do so if they want their insurance carriers to pay; if a brick-and-mortar pharmacy charges less than their standard copay for a generic drug, there is actually no reason to go through insurance at all, but rather just pay cash and bypass these middlemen altogether – something the insurers and “pharmacy benefit managers” would prefer that consumers not know about as they pay higher prices for the mail-in services.

The net effect of this is that nations like the United States that allow unfettered market manipulation pay – you guessed – more for health care while achieving less health than countries that frown on this kind of shady tactics, for example by setting formularies that account for cost-effectiveness and allowing for planned deviations when medical necessity demands.

Am I blaming Pfizer for the all the ills of the American health care system? No. But when one hand of the health care reform effort is struggling with the untamed beast of cost control – and the other hand is paying overkill prices for drugs that outstrip medical necessity – one has to wonder where the balance will be struck between innovation and affordability.

In any case, open generic competition for Lipitor will take over in the next year, ending any debate about paying full price. But the success in consumers’ and regulators’ ability to block this kind of behavior will set a long-reaching precedent in pharmaceutical patent-holders willingness to try these kind of rank shenanigans again, the next time a blockbuster drug goes off-patent. And that is something we all have a stake in.

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I stand with the 99%.

I stand with the 99%.

I have a choice, you see. I don’t have to stand with the 99%. I have an advanced degree, make a low six-figure income in an extremely high-demand field, and if I wanted, could double or triple my income without much thought beyond having to move somewhere I wouldn’t too much like. I have a rock-solid job with even greater future opportunity, as well as health coverage and a stellar disability insurance policy that costs as much as some families spend on food in a month. That doesn’t make me a millionaire (indeed, because of immense school debt and a rapid pay-down plan, there’s about three-digits worth of cash in my combined accounts at the end of any given month), but I identify with the 1% elite because I have the rarest of commodities these days: security.

But I choose to stand with the 99%.

I stand with the 99% because the biggest threat to my security is – no surprise – the $300,000 in student loan debt it took me to get to where I am today. My very generous middle-class parents took me through my undergraduate years, but I paid in cash and the blood for the graduate education – at a notorious poorly funded state school – that brought me to where I am today. I have no doubt that the nay-sayers are correct in predicting that the next great crash will be the student loan debt bubble (standing in great part on the shoulders of the rapacious for-profit vo-tech schooling institutions, but increasingly standing on the slumped shoulders of public school grads like myself).

I stand with the 99% because I know that if you reach back more than a generation or two, my people are not the people of the 1%. In the four corners of European mutt heritage from which I was hybridized, two lineages came to America escaping the twin beasts of poverty and famine back home, one’s history has been lost to the sands of time, and one came from a line of wealth but smartly realized that their people were not welcome in pre-War Europe. My people are not Daughters of the American Revolution people; my people are by wide majority immigrants and paupers but for a blip that started around 1950 and has no guarantee of continuing beyond my generation. There is no blue in blood in my veins; my people were always the 99%. I have no illusions about what I deserve today, and no illusions about its permanency into the next generation.

Even if I can rise above the 99%, I know that I am not so wealthy that I can take my friends and family with me into the magical 1%: my sister, for example, and her wonderful blended family that now welcomes seven children under its umbrella, the eldest two of whom are facing down college tuition costs with five more bringing up the rear on a couple of blue-collar salaries. Or my brother – an Iraq vet, paramedic, and firefighter – whose older daughter is marked by the chronic stigmata of surviving a year in intensive care then rehab with a rare childhood leukemia, and who will never be insurable on the private market. I can carry myself into the 1%, but if my family falters back in the mire of unpayable college tuition and bank-breaking health care costs and chronic debt, what have I won? For this reason too, I stand with the 99%.

I stand with the 99% because when I envision the world I want to live in, I do not envision a rarefied gated community to which I have a coveted key, surrounded by the ghetto of the world I used to be a part of. When I envision the world I want to live in, I do not see a world of poverty and desperation to which I am somehow granted immunity; I see a world in which we share livable cities and breathable air. I stand with the 99% because nothing about the world that I want to live in jives with the world we will create if we allow America to become a third-world nation of haves and have-nots.

Humanity has progressed through the millennia toward milestones meant to make life incrementally easier: increased agricultural production bent on easing food insecurity; diplomacy so that war was not the first answer; arts and music to make life beautiful; medicine to heal. Humanity did not bother to invent fire, the wheel, the internal combustion engine, and one-touch online ordering in order that we may work double the work hours of our parents at a fraction the pay and die younger for our troubles. Our ancestors did not do go through the trouble of millennia of invention and progress so that we could suffer like medieval peasants; our people did this so we could flower. Our people did this so that we could spend less time toiling in fields and slaving at stoves, more time playing with our kids and writing novels and shooting at beer cans and having backyard cook-outs and climbing mountains and tinkering in the garage with that invention that may be the next greatest thing or next week’s trash: more time being human and more time stretching the limits of what it means to be human.

Should we be proud of these moments of adversity overcome, these days when we struggled to make ends meet and survived and provided for our families, when we challenged the Greatest Generation on their home turf of hardship and hard work? Damn well we should be proud. I am proud that while the majority of my graduate school compatriots were on vacation breaks funded by parents or working partners, I worked 80-hour weeks at contract jobs on marine construction sites and came back so exhausted I spent the first half of the quarter catching up on sleep while pulling night shifts on academic rotations. People who are working three jobs at 60-70 hours per week through these crisis times should be able to look back with pride and tears and talk about 2011 the way our grandparents talk about the Depression. We should be proud of these things we survive.

But we should never strive to embrace them.

We should never, ever strive to make the 70-hour work week the norm, to make two jobs the minimal and three jobs the expectation. We should never allow the good old Protestant work ethic to be co-opted by neo-feudalism to the point where we begin to enforce the high-expectations/low-pay ethic on ourselves. Those who want to work 60- or 70-hour weeks should be doubly rewarded – not used to foment a new common denominator. Because if 60-70 hours a week becomes the norm, the new just-getting-by, there then becomes no way to get ahead. No way to work that mortgage down in advance and retire a little better than you might have otherwise. No way to cushion for the stochastic blow of a slow year in your industry or a bum shoulder you need surgery for. No way to set a little aside so you can take that brave step out onto the plank, quit your job, open that small business and become one of the “job creators.” No way to dream that your children might one day have it better than you. No way to save for the six months to might want to take off one day to follow your dream, or stay home with your first baby, or take care of your father in the last months of his life. No way to become anything more than a cog in the grinding wheel of someone else’s profits.

I stand with the 99% because I stand for the American way. This is not a way of laziness or sloth, this is a way that works hard but believes firmly in the limits of hard work. This is a way that believes in a good solid eight-hour day followed by a good solid eight hours of doing the other business of life: raising kids, reading a book, cooking a meal at home, watching trashy TV, keeping up on the events of your world, running in the rain, caring for your ill or your young, doing whatever it is that you do. And then, getting a good solid eight hours of sleep. Some call this “European socialism;” the rest of us call this “the American dream.”

I have a choice, and I choose to stand with the 99%. I stand with the 99%, and I am not alone.

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Against Medical Marijuana: A civil liberties argument against a humanistic farce

In 2007, medical marijuana became legal under a physician’s directive in New Mexico, one of sixteen states allowing some variation of medical use of ­­Cannabis sativa. Since then, regulation of medical marijuana in the state has swung with the political tides: founded and liberalized under former Democratic governor Bill Richardson, then tightening under current Republican governor Susan Martinez, who made a campaign vow to reverse the move toward medical legalization of marijuana altogether.

Caught in the middle of these political tides are the physicians who are asked to make the judgment call as to whether a patient is an appropriate candidate for medical marijuana. Predictably, medical providers fall into largely political camps in the decision whether to engage with the medical marijuana question at all – many refuse to sign the paperwork on an ideological basis, a few will sign any patient’s paperwork out of reverse ideological concerns, and a good number want nothing to do with it simply because they do not want the word to get out that every weed toker in town then come knocking on their door. The guidelines about who can prescribe for which conditions are only marginally helpful: a tangle of specialists needed for one condition, primary providers sufficient for another, and dual requirement from both for yet other conditions. The unifying theme behind these guidelines is that there is virtually no evidence behind a single one of them – to guide what conditions are covered, under what circumstances, and under the guidance of which specialists. In the era of evidence-based medicine, this is problematic.

But this problem is not accidental. Evidence is not a god-given entity; it is a good that must be gathered through clinical trials and observational data and then run through the grist mill of statistical analysis. The dearth of evidence for the safety and efficacy (or lack thereof) of one of the most frequently used mind-altering substances in the United States is due in no small part to a quirk of the way that the Drug Enforcement Agency classifies illicit substances: the schedule of controlled substances under the 1970 Controlled Substances Act. This law attempted to sort out serious drugs (and serious drug offenses) from drugs of more minor import, as well as drugs that have some dual role in both medicine and abuse. Schedule I drugs are the most serious offenders, with high potential for abuse and no role in medicine (they cannot be prescribed under any circumstance and theoretically cannot be permitted for research, though this rule is sometimes not strictly adhered to); Schedule V drugs are minor offenders with widely overlapping medical applications, and Schedule II-IV runs the spectrum between. You may be surprised to know that marijuana occupies a premium spot in the Schedule I category, right beside heroin, GHB, LSD, and ecstasy. You may be even more surprised to find that cocaine and methamphetamines are considered squarely less dangerous than marijuana, in the still-venerable Schedule II category (cocaine is used in some ear/nose/throat procedures; amphetamines are too close to a cluster of ADHD medications to make a useful distinction – thus the placement in Schedule II). Essentially, the DEA is far more vested in eradicating the scourge of marijuana than ridding the streets of methamphetamines and cocaine. (Interestingly, tobacco and alcohol were never rated by the DEA, probably because they are legal substances.)

It is because of this Schedule I placement that the feds take marijuana so seriously, and why state laws legalizing medical marijuana so flagrantly flout federal statute – and will likely eventually force a constitutional read of the issue at the SCOTUS level. (Several years ago, an acquaintance investigated the quandary of what to do with a notoriously brown-thumbed tenant who was producing a substantial quantity of the moldy pot plants in the drafty attic of his old San Francisco Victorian with a questionable grower’s license; in the course of his investigations, the landlord discovered that the city police didn’t care, the state law enforcement office reacted with studied indifference, the local housing authorities told him not to bother to get involved, but that every branch of the feds he contacted simply wanted to know the address so that they could initiate a bust immediately.)

It is because of this Schedule I status at the federal level that there is notably scarce data in the formal literature on the effect of marijuana on chronic pain, PTSD, depression, inflammatory conditions, asthma, palliative care, weight loss associated with cancer and AIDS, and the other conditions for which patients routinely request it of myself and hundreds of other physicians in the states where it is legal. American researchers are critically restricted from effective study of the medical effects of marijuana (except in the purified form of THC marketed as Marinol, marketed as an appetite stimulant and universally panned for its ineffectuality beside the supposed panacea of real marijuana) because forty years ago the federal government declared – in a nearly heroic accomplishment of circular reasoning – that there is no medical indication for marijuana.

And thus we set the stage for the farce that is medical marijuana. In New Mexico, physicians actually have a list of approved indications, which includes chronic pain, inflammatory arthritis, PTSD, glaucoma, painful peripheral neuropathy, and (in an ironic nod to the state’s epic battle with injection drug use) the discomfort associated with hepatitis C. We have no evidence that this substance is effective for any these conditions (nor any evidence that it is ineffective, or that it is harmful, nor that it is ineffective for a long list of excluded conditions), but someone came up with a list of inclusionary and exclusionary criteria, and there we are.

Because it is not produced uniformly and studied legally, I cannot come up with a reasonable dosing regimen at which I can expect results or move on to a different medicinal approach. I know roughly what twenty milligrams a day of Lipitor should do to your cholesterol, and how many milligrams of ibuprofen can reasonably be expected to turn off your headache pain before you risk an ulcer, but I can’t even hazard a guess at how many ounces of Mary Jane should evaporate your back pain, or alleviate your anxiety, or lighten up your mood. Because it is so poorly studied, I cannot give a patient a list of contraindications, side effects, or even long-term dangers (some claim, for example, that inhaled cannabis works well as a bronchodilator for asthma; not only do I find this disingenuous if there is no evidence to back it, there is reasonable cause to suspect that chronic marijuana smoking may be a culprit in emphysema just as well as cigarettes).

Without any kind of dosing standardization or quality control, handing out medical marijuana cards is essentially the equivalent of telling patients to open up a bottle of Jack Daniels, insert a straw, and start drinking until you feel better. Except that instead of properly bottled whiskey, make it the stuff that some guy stilled in an old bathtub out back of his cabin: it may be authentic, but the public health department isn’t exactly looking in to ensure he washed his hands first. (The state of New Mexico does license growers, but they are not inspected and regulated the way the FDA watches over pharmaceutical factories. Indeed, one of the little-spoken health concerns about marijuana is that large-scale illicit growers are not exactly environmentalists: you might be smoking some of the most potent pesticides and fertilizers on the market when you inhale a crop produced under the duress of a growing seasons shortened by the threat of federal surveillance.)

So what then to do with the patients who claim benefit from marijuana in all is chemical glory? Well, I say let ‘em smoke it. Or eat it, or vaporize it, or spread it on their toast in the morning in the form of weed butter. But get me out of the middle of it.

The medicalization of marijuana has been a shrewd and well-calculated move by the pro-legalization crowd to crow-bar the power of compassion for the terminally ill and fatefully traumatized into political capital toward the normalization – and eventually legalization – of marijuana. And fundamentally, I agree with that goal. Many decades ago, this country decided that the social cost of restricting your right to a mildly mind-altering substance was not worth the crime wave that came with trying to enforce temperance; prohibition only serves the task-master of organized crime, and in my lifetime I would like to see the United States of America come to the realization that if drinking a fifth of vodka does not warrant ruining one’s life with a jail sentence and one’s community with organized crime, neither then does smoking a joint.

But I don’t appreciated being used as a tool toward that end. The medicalization of marijuana means that I am forced into the farce of pretending that marijuana is modern medicine. Marijuana is medicine only in the way that opium poppies are medicine: there’s something in there that’s awfully potent, but I wouldn’t feed it to patients straight up if wanted a predictable effect from a set dose – which is the essence of what separates modern medicine from the stuff your great grandma boiled up in her kitchen to treat the neighborhood nose bleeds and fevers. Marijuana is medicine only in the way that that proverbial bottle of Jack is medicine: it sure does something, but as a doctor, I’m pretty sure that is a something I don’t want to be responsible for prescribing.

The medicalization of marijuana means that I spend appointment time with complex patients discussing – ad nauseum – the intricacies of who needs to sign the annual paperwork for their cards for their particular condition, instead of focusing on actual medical conditions. The medicalization of marijuana means that I field a fair number of patients who establish care only to ask for this service (only some proportion of whom are actually ill), who are severely put out to discover that I cannot provide it to them under the current guidelines and who are unafraid to tell me so in angry and explicit terms. The medicalization of marijuana means that I spend public dimes at the community clinic where I work explaining and re-explaining the guidelines and limitations of this program, verifying and re-verifying the changing landscape of requirements which – I think it is only mildly paranoid to suspect – the current right-wing regime in the state may one day use to punish physicians who veer at all from the exacting nature of the program. The medicalization of marijuana fundamentally means a large bureaucratic headache for an issue that I fundamentally feel is none of my business (and as a primary care physician, bureaucratic headaches are something I do not require any more of than I already have). Unless they are troubled by it or using it to an extent that is causing medical or mental health issues, I do not feel that marijuana use by my patients is my business, pro or con – much as a glass of wine with dinner does not concern me.

My only entry in this dog and pony show is as a half-hearted civil libertarian (of the kind that appreciates being left alone if I’m not hurting anyone else, but recoils at the rather horrifying spectacle of Tea Party libertarianism), and a fulltime harm reduction-ist, of the sort that heartily supports needle exchange programs and drug treatment over punishment for those in the throes of addiction. The full legalization of marijuana fits both those bills: get the government out of the business of busting people for a drug that is fundamentally about as harmful as alcohol and tobacco, and take the breeze out of the sails of the organized crime that has been the sole beneficiary (alongside, perhaps, the terrifyingly profitable privatized prison industry) of this late-date Prohibition. But the medicalization of marijuana defeats all these purposes: creating new headaches and bureaucracies without tackling any of the social ills of prohibition. Moreover, medical marijuana disingenuously asks doctors to play the mediator in the age-old cat-and-mouse game between stoners and law enforcement – trying to suss out whose pain is real, who is not just looking for a get-high-no-jail card – a role that I have no aptitude for and even less desire to engage in.

It is high time that the pro-marijuana crowd step up to the plate and aim their efforts at their true goal: legalization. (Or, in the interim, moving cannabis off the Schedule I list to somewhere more reasonable.) And please, spare me being shoe-horned into the middle of your efforts – I appreciate the core sentiment, but I do not appreciate the paperwork, the headache, or being used for purposes that defy the calling of my profession.

Let the ill have their relief and the hedonists have their day. And please: let the physicians practice their craft without pretending that unrefined herbiage is part and parcel of modern medicine.

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Efficiency in the health care market: A short treatise on a perplexing paradox

On any given day, you can hear talking heads on a dozen sides of the health care reform debate arguing about which version of health care delivery is the most efficient. Many lay claim to this holy grail of financing, they cannot all be right, so who is doing the truth-telling and who is doing the lying?

“Efficiency”, like many jargon-able phrases, has different meanings to different people who use the word. In classical 101-level economics, efficiency is a market phenomenon that happens when you allow an unfettered entry of buyers and sellers to a common exchange. Demand and supply sort themselves out to some sort of equilibrium, and a movement of goods occurs at a point where the maximum possible number of buyers and sellers are happy with the outcome – a mechanism essentially mediated by price. This is a dynamic process, with price rising as a good becomes more popular and sellers can demand more compensation (concert tickets on the day of a sold-out show, plywood and flashlights on the day a hurricane rolls through town), and price dropping as surpluses flood the market or goods lose the cache to drive high price (disco shoes circa 1980, manual labor in the era of mechanization). Though this kind of efficiency by no means makes everyone happy, it is one way to reach maximal contentment with minimal interference and to drive supply in accordance with demand. (This model harbors a wealth of flaws when applied to health care, but set those aside for a moment.)

“Efficiency” in the health care world has taken on a life of its own, and in looking at the cross-purpose uses of this word, we can start to understand why so many sides of the debate lay claim to this distinction – and while none of them are exactly lying, how we can use a better understanding to pick which of these sorts of “efficiencies” actually align with reasonable health care systems.

On one hand, one could reasonably use the term “efficiency” to describe how much of a system’s health care dollars go into actually health care, versus how much goes into overhead, upkeep, and general bureaucratic usage. To give you a sense of the norms, Britain’s National Health Service runs a usual overhead rate of about 5%. Medicare – America’s near-universal program for insuring retirees, run by the much-maligned US government – comes in at a spectacularly low 3% overhead rate. In both of these notably “socialist” programs, 95% or more of the cash flow runs straight to actual health care.

Private for-profit insurers in the United States routine run an 80-20 split: 80% to actual health costs, 20% to overhead and other costs. By any measure, for-profit US insurers are an entire digit less “efficient” than the universal insurers in any other developed country. Shocking, no?

Well, maybe not. Because it depends on your actual goal when you define the term “efficiency.” In the very succinct words of TR Reid in his eminently entertaining jaunt through comparative health care economics, The Healing of America:

It’s revealing that, in the lingo of the US health insurance industry, the money paid to doctors, hospitals, and pharmacies for treatment of insured patients is referred to as “medical loss.” That is, when health insurance actually pays for somebody’s health care, the industry considers it a loss. (Health insurance executives explain that “loss ratio” is a technical term borrowed from the fire and casualty insurance business.) Insurance executives, securities analysts, and the business media carefully watch each company’s medical loss ratio to make sure that the actual medical payments don’t eat too deeply into administrative costs and profits. If a health insurance company consistently spent much more than 80 percent of its money on actual health care, its stock would plummet and its CEO would be axed.”

If your goal is health care, 3% overhead is a remarkable feat of efficiency. If you goal is profit – as it is for the bulk of American coverage providers – efficiency is measured not in low overhead, but in low outlay toward “losses” – losses that, for Medicare or the NHS, add up to a whomping 95-97% of their budget. This view of efficiency (maximizing profit, minimizing unnecessary losses) would ring true for a car manufacturer, a legal services office, a retail clothing outlet – why would it be any different for a commercial insurer? Read from this angle, the American private health insurer is a star of efficiency, wringing a spectacular profit out of an industry in a manner achieved in no other developed-world nation. And incidentally, along the way, creating the most expensive health care system with some of the most notably mediocre outcomes in the developed world.

By looking through these opposing lenses, we can start to see how both the universal-coverage proponents and the free-marketeers both claim the mantle of efficiency. The question then simply becomes which kind of efficiency we want: the kind in which the cash flow through the health coverage system is maximized for health, or the kind in which the monetary investment in the health insurance industry is maximized for profit? This is a question of both desired outcomes and moral fiber of a nation. It is a question that is currently being answered for us in a variety of ways, but which behooves us to step up to the plate and take a brave stab at answer for ourselves.

Now let me put a third spin on the definition of “efficiency” – or in this case, inefficiency. Outside of the hallowed halls of academic economics and the somewhat shadier halls of the for-profit health insurance business, there are the busy and chaotic halls of your local hospital and clinic. On ground zero of the coverage debate – where physician meets patient – a different version of inefficiency arises, one that has little interest in actuarial tables and national policy and theoretic curves of supply versus demand. This is a nebulous, harder-to-define inefficiency, along the lines of how a famous person once described pornography: “I know it when I see it.” It goes like this:

On an average day, I see a certain number of patients, treat their complaints, send them on their way. And then I take a deep breath and dive into the hours of paperwork generated every day by the intentional hoops, denials, and obfuscations created by a system fractured into competing for-profit insurers. These hours are spent completing prior authorizations, appealing denials, cooking up secondary codes when insurers don’t want to cover diabetic blood tests under the code for “diabetes.” Hunting down lists of approved drugs only to receive a fax back declaring the medication chosen was actually not on the approved list, then filing a prior authorization, and then receiving a fax back declaring that oops, it actually was on the list to begin with. Memorizing arcane grids of which labs work with which insurance agencies, and remembering to choose the purple tube or the green tube before performing basic tests (and calling patients back for repeat testing if by chance I pick the wrong one, or they change insurance carriers in the interim). Fielding calls from panicked patients that a test that should have been covered was not. Fielding calls from angry patients that three weeks into a request, we still have no answer on a prior authorization. Fielding mystified looks from patients who legitimately ask, “Will this be covered by my insurance?” when the answer from me is that I have no way of answering – not only because I cannot memorize some thousands of constantly-changing benefits packages, but because if I hazard a guess, I know I will be held to it. This sort of inefficiency may not be well-theorized by the economists and financiers, but it perhaps the one that most affects your satisfaction with your health care. It is driven – both intentionally and not – by the multiplicity of insurers and the drive to deny services and maintain that 80% maximum outlay toward “medical loss,” as the insurers call it (or “health care” as the rest of us call it).

This is the soul-grinding inefficiency that makes so many primary care doctors want to flee the business altogether. It is also a rankly understated part of the reason why health care is so expensive in the US: not only are private insurers routinely skimming 20% of the health care dollars that pass through their hands, almost no model I have ever seen accounts for direct patient care time lost to the demands that insurers place on doctors. I could see several more patients per day at the same salary were it not for the trail of paperwork each leaves behind - sometimes several-fold the actual face time spent with a patient. This is time that increases insurance company profits at the expense of decreases physician income per hour - essentially, unreimbursed time providers spend working on behalf of the profit interests of insurance companies. And with delays, uncovered costs, and a thousand other annoyances small and large, this contributes mightily to the soul-grinding inefficiency that makes so many patients so dissatisfied with their primary care experience.

Single-payer (or at least more tightly regulated) systems remove a large part of this latter inefficiency by offering more uniform benefits packages that physicians might reasonably be expected to master, by forcing ancillary services like labs and imaging centers to utilize less fractured logistic practices, and ultimately by making the goal of health care to take care of people rather than to deny services. And therein allowing physicians to do what they do best – practicing medicine – instead of do what we usually do worst: push paper.

Note: Much of the background information for this discussion is derived from TR Reid’s most impressive The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care – which tackles the usual dry topic of comparative health economics in a most enjoyable format. This should be required reading for any non-expert interested in the problem of health care reform, and I highly recommend it for anyone interested in understanding the different formats of single payer/universal coverage around the world and at home.Efficiency in the health care market: A short treatise on a perplexing paradox