For Fear of Being “Difficult”, Will I Forego My Needs?

----Terri Bernacchi, PharmD, MBA, Cambria Health Advisory Professionals
A study by the Palo Alto (Calif.) Medical Foundation Research Institute published by Health Affairs this May describes what many of the “meek” already know. You don’t want to irritate your doctor with too many off-putting questions; you’d rather suck it up and trust that he/she will do the right thing. http://newsroom.pamf.org/2012/05/patients-fear-being-labeled-difficult/

Though not a random, large scale trial, the researchers confirmed something many of us who have taken care of patients already know: There is often something broken in the dialogue between physician and patient as it relates to “give and take”.  The patient often withholds information, lies, or deliberately remains quiet when the golden opportunity to ask questions, challenge, or probe for options comes up.  Think how hard it is to ask for a second opinion! 

 In December 2009, PAMF researchers interviewed 48 people broken into six distinct focus groups. The participants were randomly selected from the electronic health records of five primary-care physicians in the San Francisco area.  Maybe not suprisingly, most were white, well-educated and more than 50 years old, and 19 reported annual incomes of $100,000 or more, although the investigators believe the results apply across all demographics.


And I would tend to agree with them from my own anectdotal experience.
The researchers found that focus group participants feared to question a physician’s advice or recommendations, concerned that they would be perceived as a challenge to the doctor’s authority. Most of them wanted to avoid “displeasing” or “disappointing” their physician.

Patient-Doctor Relationships represent a fundamental imbalance in power;  some felt that their physicians perpetuated this authoritarian stereotype. To manage their care, then, many described “doing their own research about treatment options and bringing social support to medical consultations to make the best use of the limited time available.”

“Shared decision-making is a collaborative process that allows patients and their healthcare providers to make health care treatment decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences”: This requires two way exchange of information and implies accountability on both parties to actually be direct with regard to needs, wants and concerns.

It may mean that we should start early (perhaps in grade school) to encourage more effective means to encourage two-way dialogue with health care providers so that the charade of what is actually going on with a patient does not involve the patient withholding important factors or feelings (embarrassment, shame, unworthiness) that could impact care.

Terri is the founder of Cambria Health Advisory Professionals. Among her current clients: a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders. a small special needs health plan as a 5 Star Consultant, and several other health related clients. The thoughts put forth on these postings are not necessarily reflective of the views of her employers or clients nor other Health Advisory Professional colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to her current employer three years ago. She has both a BS and a PharmD in Pharmacy and an MBA.

Waste Avoidance vs. Rationing: In the Eye of the Beholder

--By Anna Shepherd, Health & Personal Finance Professional

After musing over this must-read article written by Dr. Howard Brody, a few things come to mind. I absolutely agree that the type of waste the author describes is the elephant in the room that needs to be addressed before any realistic measures can be taken to rein in healthcare spending in the United States. 

See: Brody, Howard. “From an Ethics of Rationing to an Ethics of Waste Avoidance” NEJM 2012; 366:1949-1951. May 24, 2012. Taken from the URL: www.nejm.org/doi/full/10.1056/NEJMp1203365#t=article

But I also have a few points of contention that are not directly addressed with the article.

1. It’s obvious that in this environment, trimming the health care industry from 17% of GDP to a more manageable number, say 9%, is going to be unpopular from a policy standpoint due to the sheer size of the health care industry itself (read jobs). However, this would not be disastrous as the more efficient allocation of resources in a free market would be a net benefit in the long term. However, the political will can only exist if the electorate is also willing, a political rant I will forego right now.
2. It does bring me to my next point however; I think the author asks too much of the average physician without bringing in the most important component of the equation: the patient. Patient education is the only way to really solve the waste problem, in my opinion. Unfortunately, the path to an informed and enlightened patient takes time and effort. Physicians are already inundated with large numbers of patients, ever lower reimbursement rates, malpractice threats and the cost of practicing defensive medicine, not to mention the stresses of simply running a practice. I’m not a physician, nor an expert in these matters, but it seems naïve to me to expect physicians to take on this extra task. So, there must be a better way to get the patient to make better decisions and reduce wasted resources.
3. The final issue I have with the physician-driven nature of this article is a moral one. The decision to ‘ration’ cannot come from “without”. Because the rationing we are talking about is often going to involve foregoing costly procedures, we arrive at a very gray area in which the care-taking physician must try to be an objective advisor. They are far too financially involved, as the author mentions, in the outcomes of the patient’s decisions to truly be the trusted source for advice.

Posing questions about the ethics of rationing is a great place to start the conversation. And physicians are a crucial gate-keeping mechanism to avoid waste. But I think the author may be trying to solve a problem by creating a more complex system instead of the solution I see as painfully obvious throughout the health care system. It goes to a fundamental component of economic efficiency: a system is efficient if each actor is allowed to maximize their individual utility.

Simply put: the answers need to come from the patients themselves. We need to create an environment in which patients can seek the answers and information that allow them to make efficient decisions without feeling that care has been rationed away from them. They need to own the decision.

Shifting the Power (and Burden) of Decisions to the Patient

 by Terri Bernacchi, PharmD, MBA,  Health Advisory Professionals

Sometimes people are most comfortable when someone else makes the difficult decisions in their life (and then takes the associated blame for when things turn out poorly). Others (like me) need to know all the options, odds and consequences for each, receiving counsel from trusted sources, and then making an educated decision. This is true for life decisions and for medical decisions, alike. In essence, it is for all decisions, great or small, regardless if there are just two alternative options or many.

One must weigh the options, rate the implications, and make a decision. And making no decision is still making a decision.

The link listed below contains an excellent posting about how complex medical decisions made on behalf of patients by physicians are often (when reviewed with the perfect clarity of hindsight) found to have been “unnecessary”. Key examples offered include such daily concerns as when to order a CT scan or implant a defibrillator, but these kinds of decisions are made all the time----some with little cost and consequence, some with profound cost and consequence.

Certainly, there is a theory that by applying more stringent governmental regulations on clinicians, only those patients that fit the narrow criteria for a treatment will receive it, saving vast amounts of otherwise wasted resources. As most of us who have “been there” know, it’s not quite that simple.

A recent JAMA article concluded for the 111 internal defibrillator patients reviewed,”Among patients with ICD implants in this registry, 22.5% did not meet evidence-based criteria for implantation.”

Shannon Brownlee, the author of this linked post about “Sharing Decision Making” notes one of the most challenging conundrums, using the defibrillator example, of modern medicine in the United States: physicians and patients do not make decisions in the same ways; and they don’t necessarily realize the gap between what each considers most important. http://health.newamerica.net/blogposts/2011/sharing_medical_decisions-42668#

She cites rightfully, that the implantation of defibrillators is a lucrative procedure for physicians and hospitals alike. She also makes a solid case that the decision to implant one of these devices is not always a black-and-white circumstance. Evidence-based clinical guidelines are in place to help surgeons select which patients are most likely to derive the greatest benefit. But doctors are routinely faced with patients who fall into the gray----who don’t exactly fit narrow criteria, but might receive some benefit from the device anyway and so they receive it. She also makes that case that some physicians may be unaware of the guidelines or evidence, thus not putting them into practice.
The line of distinction that I would like to draw is this one: the physician does not generate the same fees from NOT doing a procedure as he or she receives from DOING one. Thus, there is a frequently financial interest that weighs----whether recognized or not---as a potential medical conflict of interest between the objective needs of the patient (in the eyes of his provider) and that provider’s financial arrangements related to the options under consideration.

Ms. Brownlee notes that “...when patients are given a chance to be fully informed, and to share the decision about an elective treatment with their doctors, they often make choices that are very different from those their physicians would have made for them.”

In order to actively advise (as in “Shared Decision Making”) a patient on the medical alternatives without that bias weighing in by fact or appearance, a clinician must be able to divorce him or herself from the financial consequences of the “next steps” and truly sit on the same side of the table as the patient. This may not be possible in today’s medical construct and may be best remedied by a new kind of practitioner------one with experience and knowledge about how to objectively log and rank the medical alternatives, one with great listening and empathy built into their personality, but one who is not conflicted by the active practice of medicine and its payment schema. This clinician can guide and help the patient to a new kind of informed decision making----one which may reduce pain and suffering but also yield financial savings for the patient and the system alike.


Terri currently works for a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders in health care as a Senior Principal in Managed Markets. The thoughts put forth on these postings are not necessarily reflective of the views of her employer nor other Health Thought Leader colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to her current employer three years ago. She has both a BS and a PharmD in Pharmacy and an MBA.


[1] JAMA. 2011;305(1):43-49.

The Squeeze on State Budgets Means Health Care Reform (As Is) Is Infeasible

By Anna Shepherd, Health & Personal Finance Professional

The impetus for this post was the news of a small community in Washington losing state funding for health clinics due to budget problems. I think it typifies conditions throughout the country. States are already facing crippling budget crises that force them to seek federal monies to help pay for programs like Medicaid. When we consider the fact that health care spending is going to keep increasing (now at 17% of GDP—see WSJ article below) we can safely assume that states are not going to suddenly be able to pay more into Medicaid and related programs. So, the burden will fall to the Feds. However, at a time where we will inevitably (amidst much pandering to the contrary) have to raise the debt ceiling again, it only stands to reason that the money is simply not going to be there for a costly overhaul—on the state or Federal side.

Further recognition that the ACA legislation is not entirely feasible came today, as the Obama administration repealed an aspect of the bill due to start this year that includes end-of-life discussions in a regular physician appointment. When push came to shove, it wasn’t sensible and was repealed. Somehow, I think we’re going to be seeing a lot of that in the next few years. Unfortunately, it comes at a time when governmental action is a precious commodity. A gridlocked Congress already has too much on its plate just considering the budget; unraveling the labyrinth health care law seems like a Herculean effort. Nonetheless, I think we’re beginning to see a reality that was somehow not present last March.

So what’s the solution? Though it is my personal opinion that health care was passed without due diligence and if it had been proposed in segments over a longer term the sensible parts would have passed and the nonsense would have been left behind, we cannot turn back time. However, there are still actions to be taken. The first of them is a serious look at the Rivlin/Ryan proposal: people born after 1956 get a needs-based (adjusted for health risk and age as well) voucher to spend on private health insurance instead of Medicare eligibility (For more on this: http://www.ncpa.org/pub/ba736 ).

This is a start! Furthermore, as in the Forbes article linked below, companies need to take a long, hard, look at what their employees’ health means to the overall health of the company. Creating a scheme similar to 401k contributions, increasing participation in wellness-reward programs, allowing higher contributions to HSAs while funding high-deductible plans, personalized insurance products—all of these are feasible ways to make health care a more manageable part of corporate life. I firmly believe it will fall heavily on the private sector and the actions of individuals to make a difference in the state of health care in this country.

Source articles

• Washington community sees funding for health clinics cut due to budget crisis:    http://www.whidbeyexaminer.com/main.asp?SectionID=1&SubSectionID=1&ArticleID=5055
• Stimulus to states set to end with new Congress:  http://www.google.com/hostednews/ap/article/ALeqM5iSQbSnGouFW-eyk3ElbhWLELr-cA?docId=b9252430d82441d980d86e945f7af254
• Health spending at 17% of GDP http://online.wsj.com/article/SB10001424052748703675904576064173290792358.html
• Solutions for employers http://www.forbes.com/2010/11/29/health-care-reform-employee-retention-leadership-managing-costs.html?boxes=businesschannelsections

On the issue of propoxyphene, pain control and drug safety

Terri Bernacchi, PharmD, MBA, Health Advisory Professionals
As a pharmacist in the 80’s, I did not have a great esteem for the drug Propoxyphene or its various combinations. I believed the drug to be nothing more than a weak narcotic with placebo-like analgesic benefits. The product was long held in disregard by the medical community in my periphery and was believed to be pretty harmless. Old ladies and malingering patients were offered it, every 4 hours, around the clock, to deal with levels of pain that the physician may have believed were benign, self-limiting or minimal. One problem with this attitude on the use of any analgesic drug is that there is a tendency by patients to increase their dosage when their pain becomes more severe. Unfortunately, this could result in addiction and even death, especially with elderly people or folks who like to drink alcohol.

Because the product was a cheap multisource option, it had become one of the most frequently used analgesics, especially the acetaminophen combination product (and the benefit of analgesia was often thought to be due to the acetaminophen component).  Propoxyphene containing products are estimated to have had 20 million prescriptions dispensed in 2007 in the US. Propoxyphene was introduced to the US market in 1957, before products approved by the FDA had to establish anything more than safety. The drug was banned by Britain in 2005, by Europe in 2009; that same year an FDA advisory committee recommended the removal of propoxyphene-containing products, but that recommendation was rejected by the agency which believed the product still had an acceptable risk-benefit profile at appropriate doses. The FDA ordered a study of the drug's effects on the heart by the manufacturer of the branded form (Xanodyne).

Recently (on November 19, 2010), in describing its reasons for asking the manufacturers to cease producing the drug, the FDA noted that even when patients took the recommended doses of these drugs, meaningful changes could occur to the electric activity of the heart, potentially resulting in sudden death. Specifically, “These changes, which can be seen on an electrocardiogram (ECG), can increase the risk for serious abnormal heart rhythms that have been linked to serious adverse effects, including sudden death. The available data also indicate that the risk of adverse events for any particular patient (even patients who have taken the drug for many years) is subject to change based on small changes in the health status of the patient, such as dehydration, a change in medications, or decreased kidney function.” (See the FDA announcement at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm234350.htm )

It is clear to me as I look backward to those years that the medical, nursing and pharmacy communities may lose perspective on frequently used drugs like propoxyphene. We may forget that what we ask the patient to do vis-à-vis dosing instructions and guidance on how to handle side effects may not actually be what they do when they go home. Instead, they follow predictable patterns of self-care and they may not understand the consequences of their actions when they increase the dose because the pain relief is inadequate. I’m not sure that it amounts to callousness on the part of the medical practitioner so much as the stickiness of the routine and the mundane in our daily efforts.
Although there were people trying to get the drug removed since 1978, it was not until the recently released study that a definitive decision was made. But it does give me a new respect for the potential for any drug----even those that we think are completely safe or even inconsequential----to cause harm.
Terri currently works for a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders in health care as a Senior Principal in Managed Markets. The thoughts put forth on these postings are not necessarily reflective of the views of her employer nor other Health Thought Leader colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to her current employer three years ago. She has both a BS and a PharmD in Pharmacy and an MBA.

Impending FSA Change Rules by IRS Creates Interesting Contradictions in Logic

--By Anna Shepherd, Health & Personal Finance Professional
The government recently published new rules, effective at 2010 year’s end, that change what an FSA (Flex Spending Account) covers at the local pharmacy. They will no longer be permitted to cover over-the-counter medications such as pain relievers or cold medicine. My focus is on an article that involves the coverage of breast pumps and the bigger picture.

The NY Times article (see Link below) explains a strange irony in US tax law that allows acne treatment to be paid for by a pre-tax FSA or HSA, but will not allow breast pumps to be covered. Personally, I don’t understand why it makes fiscal sense to make it MORE difficult to self-fund health care expenses especially in this climate. And why would something so natural and so relevant to health care be explicitly excluded? http://www.nytimes.com/2010/10/27/business/27breast.html?src=busln

Well, I did some research and the best answer I found? Taxes. It can cost upwards of $500 for a pump and accessories and it appears that the IRS is worried about abuse which will reduce tax yield. Furthermore, the people that save the most are the ones in the higher tax brackets, aka the “wealthy”. That’s all, the bottom line.

Now, to avoid going into a rant about the inherent absurdity of letting the IRS decide that something mothers have done for millennia is “not medically necessary”, though I would really love to, I’m going to talk about the greater implications of this story.

To get around this inconvenience and still be able to purchase the soon-to-be excluded items, all you need is a doctor’s note. Not too hard, right? But why does it make sense to make someone have to make, and more importantly pay for, a doctor’s appointment to get an official doctor’s note to save money on aspirin, cough medicine, breast pumps and the like? You know you need these things to stay healthy; a doctor didn’t have to tell you that. Why would you force someone to enter into the system and jump through an extra hoop to get some very basic medical supplies? It is, plain and simple, a waste of time for all involved.

More importantly, I think the biggest implication in these new rules is what it means for the future of FSAs and similar plans. When health care costs per person are increasing at unsustainable rates, why wouldn’t you want to help people, any proportion of society really, help themselves? These accounts make sense! They make health purchases a reality connected to your own bank account rather than some abstract insurer. They force you to plan ahead and think about what is important in your health. BUT, as the Times article said, FSAs are slated to cost the government $68b (in tax revenues) in the next decade. And as I stated before, they are most beneficial to the higher earners. You do the math. I feel like this might just be the beginning.
   
PS: http://technorati.com/women/article/irs-refuse-tax-break-on-breast/
I couldn’t resist mentioning this: As this blog on Technorati indicates, the IRS deems baby formula a “necessary expense” for mothers on the WIC program (a USDA nutrition program for Women, Infants and Children). The government spent over $200m in 2009 to subsidize it. Irritating anomaly, no?

Is Shared-Decision-Making Compatible with Current US Medical Delivery Models?

By---Terri Bernacchi, PharmD, MBA, Health Advisory Professionals

Based on the title of this log entry, you already understand the premise of this debate. The current US Medical Delivery Model is probably not ideally tuned into the concept of Medical Shared-Decision-Making. At its root, this philosophy involves a patient who is actively, rather than passively, involved in driving his own treatment. It implies that the patient (and family members theoretically most affected by his health) has enough information about the options available and the consequences of his own behavior on successful outcomes.

Surprisingly, perhaps, the discussion of these concepts in the literature is just beginning to mushroom, but the patient and his or her active compliance has always been the 800 lb gorilla in the room. Ask any cardiologist what the most important variable in a patient’s outcomes, and he is likely to tell you that it is the patient himself. How much salt; how much exercise; how compliant is he with necessary medications and diet?

While it’s amazing to me that this has taken so long to be center-stage in health care, our financial realities may the primary driver for why it will finally happen. Shared decision making is now a topic of global concern as individual governments face bankruptcy and austerity world-wide. To be sure, in those countries where the government funds all or most of the health care cost, the common sense reality that is sinking in is for reformation starting with how the patient himself figures into the system.

For example, the recent debate over this concept in the United Kingdom within the NHS has centered on reluctance on the part of clinicians to offer a choice (see October 22 blog). The British government is undertaking reforms as part of wide-ranging changes due to be implemented in early 2011, with a renewed emphasis on joint decision-making by patients and healthcare professionals. (See the recent article in the Irish Times by a medical doctor, Muiris Houston, discussing the debate: http://www.irishtimes.com/newspaper/health/2010/1026/1224282000782.html )

One downside is the time it consumes. After all, it takes precious time from the doctor-patient interaction to discuss the alternatives---and it is hard to think about how to squeeze more time out of a day, without adding a lot more cost. And even with that, there are some patients that want the doctor to make all the decisions about what is best for them.

The same is true in the US, where the business model of the medical practitioner centers on how to treat an acute disease, provide preventive services such as vaccinations and monitor vital signs, adjusting medication, diet, and exercise programs to delay chronic disease. The patient (or more commonly, the health plan) pays for the service and the doctor moves through the day like a conveyor belt, seeing patients, making decisions, and filling out paperwork.

The article in the British Medical Journal suggests that least three factors are critical to boost shared decision-making to its place as centerpiece of clinical practice:  

1. ready access to evidence-based information regarding;
2. clinical guidance on how to rank the options;
3. a supportive clinical culture that facilitates patient engagement.

My position on this is simple: The first three things are possible now more than they ever have. The #3 factor is coming, albeit slowly, but is being forced by the economic tsunami we are facing with our aging populace.

I would add a fourth factor: someone besides the primary clinician (who stands to gain financially each time a visit is made, a test ordered, or a surgery performed) needs to be available to talk frankly to the patient about his circumstances----helping to objectify the decision and weight the factors that are within the control of the patient. This advisor MUST NOT be involved in the recommendations nor the path chosen (and therefore cannot be paid by the insurance company to contain costs or the doctor’s office, to promote procedures). The patient can see his advisor on his own terms, referred by friends, the health plan or the doctor. But it is the patient’s own decision that is the critical path.

This is the basis for the evolving business model promoted by Health Advisory Professionals, LLC -----seeking a future state where the empowered patient understands the options and consequences and makes rational decisions based on what is right for him or her, as only he or she can know. 

Terri currently works for a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders in health care as a Senior Principal in Managed Markets. The thoughts put forth on these postings are not necessarily reflective of the views of her employer nor other Health Thought Leader colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to her current employer three years ago. She has both a BS and a PharmD in Pharmacy and an MBA.