Health Business Blog

Health care business consultant and policy expert David E. Williams share his views

Patients’ views on pain and remaining human in the hospital

There are two good patient care articles in today’s New York Times. Insurrection on the Mighty Ship of Health Care, written from a doctor’s perspective, describes the ultimately futile attempt of a patient to maintain her humanity in the hospital.

Doctors are often caught in this uneasy halfway house between medical reality and the wishes of a patient, a patient who probably knows plenty, but insists on putting on a happy face, and it raises a basic question. Is it up to us to rub a patient’s face in her own frightening situation, to overwhelm the tricks and sleights of hand used to maintain sanity?

A Fight for Full Disclosure of the Possible Pain describes the author’s experience of undertreatment for pain after knee surgery, and laments the Drug Enforcement Agency’s policies, which are causing doctors to be fearful about prescribing adequate pain relief.

[A] mass uprising by doctors and patients in support of legitimate pain treatment is overdue.

I agree.

At-home genetic test kits

The Detroit News reports that companies are beginning to offer consumers genetic screening tests to indicate predisposition for various diseases including breast and lung cancer, blood clotting, and cystic fibrosis. The customer takes a swab from inside the cheek, mails it in, and views the test result on line. Tests cost a few hundred dollars.

I’m a proponent of consumer choice and access, but there are problems with these tests:

  • One reason the tests are being offered on a consumer pay model is that it doesn’t make sense financially for insurers to pay for population screening for most disorders
  • “Predisposition” is a loose term –the genetic mutations identified may account for only a small proportion of the risk. Many people with a genetic predisposition will never get the disease –but once they have the test result they will be forever worried
  • In many cases there’s not much a consumer can do to change the likelihood of disease onset

Older patients often receive less care than they should

Today’s Boston Globe reports that older people with chronic illness receive less aggressive treatment than younger patients, and that age bias is often the cause. A few reasons are given:

  • Older people are often excluded from drug trials. As a result there isn’t good information on appropriate dosing or efficacy
  • Doctors assume older people won’t be able to tolerate aggressive treatments
  • Older people often confuse chronic conditions with the normal aging process. And doctors apparently share this view to some extent. The Globe cites a survey in the Journal of Gerontology indicating that 35 percent of doctors believed increased blood pressure was a normal consequence of aging, although it is not

I’ve seen some evidence of this problem recently:

  • In my consulting work on clinical protocol development, physicians conducting studies on behalf of pharmaceutical companies complained that the studies insisted on too many exclusion criteria (which would tend to knock out older people taking multiple medications). These criteria contribute little to the outcome of the trials, but severely limit the generalizability of the results
  • An older relative of mine was initially denied chemotherapy due to his age. When the family pushed hard for it, the doctors went along and he responded well to the chemo

One of the advantages of Mark McClellan’s leadership and the new Medicare drug benefit is that we are already seeing a push at the Federal level for treatments to be tested on older people.

Hospitals’ new problem: Patients who cannot leave

Today’s New Jersey Star-Ledger reports today on

“extended stay” hospital patients, who for reasons ranging from insurance problems to lack of family support, remain stranded in their rooms, taking up needed beds for weeks, months, and in rare cases, years… Often, these patients are a reason people are held in the emergency room for hours waiting for a bed on a patient floor.

One reason patients are stranded is the long waiting lists for follow-up care facilities. Another is that no one will accept patients without insurance once their acute care is finished.

Once again the result of a poorly organized health care system is over use of the most expensive resource.

Surprise! Medicare spending estimate rises again

According to Modern Healthcare:

The Congressional Budget Office upped its 2006-15 Medicare spending estimate by $70 billion to about $5.5 trillion, primarily because of higher estimated costs under the new prescription drug benefit… The CMS recently estimated net federal spending on the benefit at $723 billion for 2006-15… Meanwhile, the agency said President Bush’s Medicaid proposals would yield smaller net savings than expected, $8.5 billion through 2010 instead of the $13 billion projected by the White House.

How soon until we see some serious efforts to use Federal spending power to negotiate for lower prices or impose price controls? If the pharma industry’s image continues to decline, whether because of safety issues, marketing practices, resistance to reimportation, or pricing increases, I predict we’ll see major pressure by the 2006 election cycle. It may start with “voluntary” controls on price increases to Medicare as Pharma sees the writing on the wall and gets nervous.

Interesting to see the President claim Social Security is going bankrupt while he simultaneously spearheads policies that threaten Medicare’s viability.