Commercial Free Speech Trumps Physician Privacy

In yet another slam on the medical profession by the judicial system, a federal judge has declared New Hampshire’s Prescription Restraint Law unconstitutional.

The law, which was passed by unanimous vote in the NH legislature and signed into law in 2006, made it illegal to sell or licence prescription data that identifies the prescribing doctor. It did not restrict the use of prescribing information for law enforcement purposes, research purposes, educational purposes, compliance review purposes, or for any non-commercial purpose.

The law was appealed by two data-mining companies, Verispan and IMS Health, whose business is buying and selling physician prescribing information almost exclusively to pharmaceutical companies. They argued that the law restricted their constitutional right to free speech .

Free speech?

So Big Pharma has a right to receive my private information because those who sell my private information have a free speech right to share that private information? That seems ridiculous to me. But here it is, straight from the Judge’s opinion:

Here, the challenged Law restricts speech by preventing pharmaceutical companies from using prescriber-identifiable information both to identify a specific audience for their marketing efforts and to refine their marketing messages…Such laws are subject to First Amendment scrutiny because they affect both the speaker’s ability to communicate with his intended audience and the audience’s right to receive information.

What about my privacy?

Well, it seems that because I am a physician, I have little right to privacy. At least that’s what Judge Barbarado, who was the sole “Decider” on the case, says…

Health care providers cannot credibly claim that they have a reasonable expectation that their prescribing practices will remain private because prescriber-identifiable data is routinely disclosed to patients, pharmacies, insurance companies, medical review committees, and government agencies. In other words, because health care providers work in a “closely-regulated” industry, they have at best a diminished expectation of privacy with respect to their prescribing practices.

What next?

At least 5 other states have similar laws upcoming in their legislatures, and are watching this case closely. We will see what they do now.

I hope that the state of New Hampshire will appeal the judge’s ruling. And I would argue it from the privacy standpoint, despite what Judge Barbarado says. I would argue that I do have privacy from those who would use my prescribing data solely for marketing purposes.

Otherwise, one could argue that any data collected for regulatory purposes is free for sale to anyone for marketing purposes. And that just doesn’t seem right to me

Grand Rounds at Shrink Rap

Grand Rounds is up this week over at Shrink Rap, a tripartite blog by three psychiatrists. Head on over for the best of the medical blogosphere. They even have a podcast!

Photo: Wrapped Coast, Little Bay, Australia, 1968-69. Christo and Jeanne-ClaudeCo-ordinator: John KaldorPhoto: Harry Shunk

When Cancer Strikes Close to Home

I saw a very concerned patient last week. Her 59 year old sister had recently been diagnosed with early stage breast cancer on a routine mammogram. All of my patient’s friends were telling her she had better see her doctor right away and get additional testing because she was now at increased risk.

My patient, who is 50 years old, had a normal breast exam and a recent negative mammogram. Her sister had had a negative BRCA test. There was no other family history of breast or ovarian cancer, or any other cancers identified with known gene mutations.

My patient was shocked when I told her that her sister’s breast cancer did not increase her risk of breast cancer high enough to warrant anything other than routine screening. Her sister’s breast cancer, being post-menopausal, the only one in the family and occuring in the absence of a BRCA mutation, was almost certainly a sporadic cancer. I explained that only 10% of breast cancers are genetically-linked.

We went through my patient’s Gail Model predictions together, and I showed her that her sister’s cancer raised her 5 year breast cancer risk infinitesimally, and her lifetime risk from 9 to 15%. But the Gail and other risk assessment models do not take BRCA results into account, and her sister’s negative BRCA result pretty much nullified that increased risk based on family history. Of course there is always a tiny chance that the test was a false negative, but in the absence of any other family history and her sister’s age at diagnosis, I felt that these odds were low. Finally, even if she did have a 15% risk, that risk is not high enough to warrant routine breast MRI at this time.

We looked at her last mammogram report. I explained that I usually order routine sonograms when the radiologist reports that the breasts are of increased density that limits the sensitivity of the mammogram. But my patient’s breasts were described in the report as being “heterogeneously dense”, a very common descriptor in routine mammograms in her age group. I did not see an indication to order routine sonogram.

I gave her my mantra – Everyone who gets a cancer is part of a family, but not all cancers are familial.

She understood but remained worried. Couldn’t we do something?

So we agreed that we would add a sonogram for now. I explained that because it was not clearly indicated, her insurance would most likely decline to pay for it and she was comfortable with that. My plan was definitely not evidence-based and unquestionably a medico-legal punt, but my patient left feeling her fears had been addressed.

I made her repeat the mantra back to me. “Everyone who gets cancer is part of a family, but not every cancer is familial.” I hoped if she repeated it enough it would sink in.

But when cancer strikes so close to home, it’s hard not to worry that your home is the one with a bull’s eye on its roof.

Road Trip to Athens, Georgia : Part 5- The Athens Music Scene

Athens is known for its music scene, and is most famous for being the home of the bands REM and the B52’s. The clubs and bars of Athens are alive with new music, fueled by audiences filled with students from the University of Georgia. But if you’re hanging with my brother and his wife and their friends, you don’t need to hit the bars to get a taste of Athens music.

Megan Baer

We were privileged to listen to Rachel’s friend and fellow-Philly suburbs gal Megan Baer sing at a wine-tasting and book signing party at the Georgia Botanical Gardens. Megan has a soulful and sultry voice, and sings her own stuff, plus some really nice covers. I really like her sound, and wish her great success!

Check out Megan on her my space or head to CD Baby to hear samples from her CD Out of Place.

Betsy Frank and the Bare Knuckle Band

Betsy is yet another friend of Joe and Rachel’s. We didn’t get to hear Betsy in person, but she was featured for a full hour on It’s Friday, WUGA’s end of the week music show, while we were there. This is the kind of music you’d love to hear in a bar on a Friday night with a beer in your hand and good friends around to dance with. You can hear Betsy on her MySpace. Be prepared to get up and move!

Cyndi Lauper

Well, technically, Cyndi wasn’t singing in Athens. But she was singing on Dan’s widescreen TV, and Dan lives in Athens, so I’m counting it. This performance of Cyndi singing “Carey” is one of the most incredible covers of a Joni Mitchell song I have ever heard (or seen). It won’t have the same impact if you’re not sitting on Dan’s sofa late at night after a few glasses of wine, but do click on the YouTube player below and witness this new standard.


I have to thank Dan again and again for sharing this incredibly special music video with us. Although I think next time he should move the TV out onto his new back porch so we can watch it while sitting in the hot tub. I think Cindy would like that, don’t you?

Next Up: Rachel’s Crab Cakes

Today’s Health News from TBTAM

These news stories came my way today via my list servs and friends (thanks, Susan!).

Texas Legislators vote down mandatory HPV vaccine.

In a 135-to-2 vote that appeared veto-proof, the Texas House gave final passage on Wednesday to a Senate bill that bars the state from ordering the shots until at least 2011. Even many supporters of the governor resented Mr. Perry’s proposal as an abuse of executive authority.

It was the right thing to do. The push for mandating the vaccine was coming from Big Pharma, and not the healthcare community.

BTW, Did you notice the Gardasil ad aimed at teenage girls on American Idol this week? Direct marketing to teens! I had a patient who says her daughter is wondering if she should get the vaccine because her friends “are all getting it”. Who would have predicted that a vaccine would be the new teen trend? Maybe they could combine it with a tatoo….
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New York Governor Elliot Spitzer proposes legislation to strengthen abortion rights in my home state.

Mr. Spitzer’s proposal would remove abortion from criminal statutes and make it a matter of professional and medical discretion. It would also repeal an old statute “that criminalizes, among other things, providing nonprescription contraception to minors,” according to the governor’s office..

While the proposed legislation will not change the new laws, it will create an environment in New York where doctors can feel freer to practice medicine that does not place their patient’s health in conflict with their own fear of recrimination .
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We’re all on the take from Big Pharma.

Nearly 95 percent of physicians in the United States receive free food,beverages, drug samples, sports tickets or other benefits from drug company sales representatives eager to influence their prescribing habits, according to a report today in the New England Journal of Medicine.

I stopped seeing reps this past year, and haven’t missed ’em. I admit, I still take lunch when they show up to see the docs who practice down the hall. I think I’ll stop that now.

Road Trip to Athens, Georgia : Part 4 – Out and About in Athens


We spent three days in this delighful college town, home of the University of Georgia. What made it most special, of course, was that we were hanging out with Joe and his totally cool family and friends. But the town itself has lots to offer visitors, and I encourage you to add it to your list of places to visit. Rather than bore you with the details, I’ll just give you some of the highlights. And since this purports to be a food blog, I’ll start with …

Where we Ate

  • The Grit:
    My favorite place in Athens. Great vegetarian food served with a bit of attitude and lots of flavor. I love the look and feel of the place. Old bulding, lovingly revovated, very casual and hip.

    Check out this veggie stir fry. The portions are huge, the prices moderate.

    The kids love the mac and cheese.

    They even have a cookbook!

  • The Jot ’em Down
    The Jot Em Down is an old local country store that has been revived as the same plus barbecue. It’s name comes from what you do with the list of things you need from the grocery store – you jot ’em down.

    And what a coincidence – I had just jotted down “Buy deer head and new baseball cap” and there they were!

    This is genuine beef and pork barbecue, smoked out back in a steel shack, served with sides such as cole slaw and cabbage cooked in creamed soup with crumbled crackers on top. No haute cuisine here, just typical Southern food served on styrofoam platters, so roll up your sleeves and dig in!

    The pulled pork sandwich is a classic. It’s mildly spiced, so add the hot sauce.
    And there was plenty of hot sauce…

Where We Wished We Had Eaten
No time to check out Five and Ten, run by award winning chef Hugh Acheson. Definitely checking this place out next year…

Shops We Liked

  • Dynamite
    This upscaled-looking thrift shop is my kids’ favorite place to shop in Athens. Great selection, everything totally retro and now completely in. Every mannequin was dressed just like my girls.

  • Jackson Street Books
    I found some great used jazz Cd’s here, and Nats got a book. But the best part was their parking ticket crusade, mounted in protest to the new one hour parking limit in town. Bring them your parking ticket, and you’ll get the price of the fine off your purchase!.

  • Used Records/CD Store
    I have no idea what this place is called, but we had a great time there. The vinyl records are organized by decade, so if you are my age, you can head straight to the 70’s and 80’s and buy back all the albums you sold at your yard sale when you coverted to CD’s..


Other Things We Did

  • Georgia Botanical Gardens
    Still a work in progress, so it’s small. But all the plants are native. The hiking and jogging trails are apparently well used…

  • Watson Mill Bridge State Park
    About a half hour outside of Athens, this was an idyllic place to spend a spring afternoon sitting on the big flat rocks in the river and watercoloring with the kids. In addition to beautiful views, the park has horseback riding, camping and hiking trails. Here’s the original and my water color.

And for some real art, we went to…

  • Georgia Museum of Art

Small, making it just the place to bring kids for a quick dose of art. They were having an exhibit of wearable and fabric art by Mariska Karasz, a mid-centruy designer and artist. Concurrently, the students at the University of Georgia were having their own exhibition on campus of works inspired by Karasz. It was such a treat to see both these wonderful exhibits!

Next up: Athens Music

Abortion and Breast Cancer – Once Again, There is No Link

Once again, a well-done study, this time a prospective cohort study from the Nurse’s Health Study, has failed to reveal a link between abortion and breast cancer. The findings were published in the Archives of Internal Medicine this week.

This study joins the ranks of a myriad of other well-done studies showing the same thing. To top it off, a large workshop convened at the National Cancer Institute in 2003 found no causal link between abortion and breast cancer.

And yet, if you were to google “abortion and breast cancer” or “breast cancer and abortion”, almost every result in the first 10 pages of the search results are links to non-medical sites stating that there is a causal link between abortion and breast cancer. The only exception is the NCI’s fact sheet on the topic, and occasional news articles about the “controversy”, which give equal voice to the facts and those who would distort the data for political reasons.

This is where the web’s power breaks down as far as I’m concerned. Those who know how to can manipulate the web so that a search for real medical data becomes akin to finding a needle in a haystack.

Here are just two links to information on this topic from reputable medical organizations:

National Cancer Institute Fact Sheet on Breast Cancer Risks

American Cancer Society Information on Breast Cancer Risks

and a good article by CNN:

Harvard Study Latest to Discount Abortion -Breast Cancer Link

I challenge those of you who value scientific opinion and review over politics to blog about this topic and to provide your readers a link to one of the above information sites on your blog. Let’s give these sites the hits they deserve and get them their well-deserved place on a google search.

Women deserve nothing less.

Road Trip to Athens, Georgia: Part 3 – The Blue Ridge Parkway

The hardest part about planning this trip was realizing that we did not have enough time to do the entire Blue Ridge Parkway. This national highway treasure stretches almost 500 miles from the Shenandoah National Park all the way to Great Smoky Mountains National Park in North Carolina. Hiking trails, fishing, and camping abound along the way, and the views can be spectacular.

We chose to travel a middle section from just outside Roanoke to Fancy Gap, NC. The views in this section are not as rugged as those I remembered along the Skyline Drive portion of the Parkway, but there was plenty of beauty and a few bits of local color.

We stopped for lunch just off the Parkway in a town called Meadows of Dan. We were wondering who Dan was, but we had it wrong. Apparently, years ago, the founders settled the area near the Dan River, and noting the low uniform height of the trees, which at that time were reseeding after a forest fire, coined the town’s name.

We ate at the Poor Farmer’s Market, a produce stand, gift and sandwich shop in this tiny town.

There was a bit of a line at the sandwich counter, so we had time to eavesdrop on the locals sitting in the rows of big wooden rockers there. I learnt me how to pour “ceement” to hold down a persnickety fence post, and watched with amusement as Karen behind the counter ordered one of the men up out of his rocker to make some more fresh coffee, which he grudgingly did.

We had sandwiches, chips, milk and soda. (No bottled water here, dear.) All very good, thank you. Not as good were the fried pies we had for dessert at Becky’s Fried Pies, a sweet little pastry shop next door. I suspect that these pastries, which are made from homemade dough and store bought fillings, are well-loved by the locals, but they were a bit too greasy for us.

Meadows of Dan is part of the Crooked Road, Virgina’s Heritage Music Trail celebrating and preserving the history of gospel, bluegrass and mountain music of this area. Too bad we couldn’t stay around for the Square dancing…

and too bad we somehow missed Mabry’s Mill, a working grist mill and one of the most photographed spots along the Blue Ridge…

Billy Humphries, Forest Resource Consultants, Inc. www.forestryimages.org

but we were on a roll to Fancy Gap and back to the highway.

Next stop: Athens, Ga.

Road Trip to Athens, Georgia – Part 2 The Road to Roanoke

My goal for this trip was to avoid fast food and dumb hotels. Road food was okay, so long as it was truly local, but no chains. The hotel could be part of a chain, but had to have some individuality to it, and could not have those dumb hangers or the lights and TV bolted down, or serve little white powdered donuts for continental breakfast in the lobby. Was I asking too much?

We started our trip in Philadelphia, having spent two days there with Mr TBTAM’s family for Passover. Thus, time for our first road meal came as we were heading west on the Pa turnpike toward Rte 81 south. The junction of these two routes is Carlisle, Pa, and that was where we decided to stop for lunch.

Carlisle, Pa

Carlisle is home to Dickenson College, and like all of the cities we encoutered on this trip, clearly in a revival fed mostly by the arts community. We found antique shops and galleries and had quite a choice of places to eat, finally settling on La Luz, a gallery-coffee shop-cafe. A group of students and their teacher sat nearby on sofas and chairs holding a Spanish reading class, and folks everywhere were using their laptops and taking advantage of the free WiFi. Though nothing terribly special, the food was just fine, and we had salads and soups.

Afterwards, we stopped in at The Carlisle Arts Learning Center, a huge, light-filled community studio, to see their latest student exhibit. The potter’s wheels were inviting, and we would have loved to have stayed and taken a pottery class, but we had places to go and things to do…

So it was back to the road, feeling like we’d not only avoided the road food, but found a funky little town to stop at again next year. Did I mention that this trip south is becoming our annual spring pilgrimage?

Route 81

For those making a similar pilgrimage, the big question is – Rte 81 (and the trucks) or the Skyline Drive-BlueRidge Parkway? We opted for 81 for the north part of our trip, hoping to take advantage of the earlier spring farther down south for the Parkway.

Despite our choice, Rte 81 was a picturesque way to go. We passed trucks filled with chickens and horses, and I was heartened by the many thousands of cows we saw along the way, cows that were grazing on green grass and not being fed processed dead animal, antibiotic-laden feed.
Roanoke, Va.

We spent the night in another up and coming funky little town, Roanoke, Virginia, where I had scored a great web deal at the landmark Hotel Roanoke.

This Tudor-style giant hotel, which looks pretty much like it used to up there, sits high up on a hill, linked right to the downtown by a covered footbridge. The hotel was everything we wanted, except that the outdoor pool was still closed for the season. Don’t you love the lobby?

Downtown Roanoke is a wonderful mix of the old and new and has a great small town feel. Our girls wanted us to move there. In fact, we met quite a few ex-New Yorkers who have settled there, drawn to the growing arts scene, low cost of living and great old buildings. A new art museum is going up next to the train tracks, testimony to the permanence of the transition.

We had a great dinner at Tong’s Thai, located on Salem Street in a wonderful old building. My Thai beef slad was perfect. It was a quiet night, so the owner hung out at our table and chatted, and brought us samples of curries and appetizers on the house. He had come to Roanoke from Thiland via Queens, so we had lots to talk about.

After dinner, we wandered around a bit, though most of the stores were closed. We did stumble upon a local theater that was having a reception following the opening of a play, so we crashed the party for a while evesdropping on the locals, snarfing up some free drinks, and even getting a free baseball cap!

Next we found a painting class going on at the nearby gallery, and the owner invited us in to observe the class and check out the gallery even though it was past closing time. Turns out she was from (where else) New York!

Then it was back to our room in time to catch “24” (Thanks, Linda, we are all addicted)

An early start next day led us downtown for breakfast at Ernie’s, a real local’s place serving typical southern breakfasts on paper plates with lots of grease. Don’t look for great food here, just good Southern atmosphere (and great accents).

Roanoke has a daily downtown farmer’s market, which was just getting started for the day…

and I picked up some fresh herb plants to bring to Joe for his garden.

There were lots of cute shops selling clothes we girls loved…

a Food Court in the old City Market Building, once home to meatcutter’s stalls.

Not expecting to enjoy Roanoke as much as we did, we were disappointed to have had such a short stay. But we needed to move on, so we left Roanoke mid-morning, vowing to return again next year for a longer stay.

Next up: The Blue Ridge Parkway

Outrage

Today’s Supreme Court decision constitutes an absolutely unprecedented intrusion into the practice of medicine and into the relationship between a woman and her doctor. Every physician in America should be outraged. And to not provide an exception in the law for the health of the mother shows complete and utter disregard for women.

One shining star in this dark sky is Ruth Bader-Binsberg, who was so outraged that she chose to read her dissenting opinion, apparently something rarely done. Here’s just a little of what she said:

In sum, the notion that the Partial-Birth Abortion Ban Act furthers any legitimate governmental interest is, quite simply, irrational. The Court’s defense of the statute provides no saving explanation. In candor, the Act, and the Court’s defense of it, cannot be understood as anything other than an effort to chip away at a right declared again and again by this Court—and with increasing comprehension of its centrality to women’s lives.

I encourage you to read Bader-Ginsberg’s opinion in its entirety. It is brillliant, beautifully written, and utterly dismantles the majority opinion. She shows without a doubt that those in the majority chose to completely ignore not only the legal precedent but every bit of legitimate medical evidence presented to them.

You may argue all you want as to whether or not you personally believe in abortion, but at this point in time, abortion is legal. The courts have no right to decide what technique a physician uses to perform that legal act. That decision is made by the physician and the woman, with her health and best interests in mind.

It is time that the Supreme Court take down the statue of Justice that stands at their doorstep. Let’s stop pretending that justice is what this court hands out. For justice is a woman. And this Supreme Court has no right to display her as their icon.

Road Trip to Athens, Georgia: Part 1 – What to Bring

Well, it’s been a long time since my fingers have graced these keys, and it sure feels good to be back. I’ve missed you all, and am looking forward to some serious catching up time this week.

So where have I been? On a little road trip, that’s where. And I’m here now to tell y’all about it. So pull the old pickup out of the shed, fill up the tank, roll down the windows and crank up the Rockabilly ’cause we’re heading down to Athens, Georgia to visit my little brother Joe…

It’s a long drive, so better bring along something to do in the car. Here’s what we brought along:

Books on CD:These are especially critical if one of your kids gets carsick when she reads in the car.

Feed by MT Anderson. A fabulous suggestion from daugher Nats. Narrated by a young teen who falls for a girl in a future America where everyone is plugged into the web via an implant in their brains, through which they are fed constant marketing messages matched perfectly to their live’s experiences. Chilling, and not so far off from a possible future. Not to mention a great opening line:

“We went to the moon to have fun, but the moon turned out to completely suck.”

Lizzie Bright and the Buckminster Boy by Gary D Schmidt. The sadly beautiful story of an unlikely friendship between Turner, a young minister’s son, and Lizzie Bright, the grandchild of former slaves in Phippsburg, Maine in the early 1900’s. Lizzie lives with her grandfather on Malaga Island in a racially-mixed community destined to be destroyed by the greedy townspeople of Phippsburg, who seek to turn the “Island of Maroons” into a resort community. Although the two children are fiction, the story of the town and the islanders is a true one. The author also weaves in nature in beautiful ways, giving the sea breeze it’s own role in the story, and making the reader long to ride with the whales.

Drive Time Italian. Learn Italian while you drive. Within the first few minutes, you’ll be saying many wonderfully useful travel phrases such as “Il camion e blanco” (The truck is white) and “Vedo un segno giallo” (I see a yellow sign). Actually quite a nice little audiocourse. We have till July to learn Italian, so this wasn’t a bad start.

Podcasts
It’s also not a bad idea to load up your IPOD with a few PBS podcasts to listen to when daughter Em asks for silence in the car so that she can do her homework. Here’s what I listened to:

China on the Rise: Paul Solomons’s seven part series from The News Hour with Jim Lehrer on the emerging economic giant. Fascinating.

NPR Fresh Air. My all-time favorite radio interview show.

World Cafe Words & Music from WXPN: Ah, WXPN – One of the radio stations I missed the most when I left Philly for NY. Now I can listen on line. If only Sleepy Hollow was on podcast…

NPR
We had a great little directory of stations nationwide that we tuck in with the maps so we’re never without our feed. But you can go online before you leave, punch in your trip route, and print out a personalized NPR Road Trip.

Books
Okay, our listening needs are taken care of. How about some actual reading material? I brought The Namesake, Mr TBTAM read Nelson Demille’s latest book, and Em plowed through The Invisible Man.

Casino Royale
Oh, all right. I’ll admit it. We did pick up one movie along the way…Nats got through the first half hour in the car before we had to pull over for her to settle her stomach. We watched the rest in the hotel room the last night on the road. One of the best title sequences in a long time. More violent than I think 007 should be, but I would still recommend it. And be prepared for your libido to kick in, ladies, the new 007 may not be Sean Connery, but he is one hot dude…

Great Music
We’re heading South, so grab those Dixie Chicks CD’s. We also listened to John Mayer’s Continuum, and Joni Mitchell and Paul Simon, and Gillian Welch. We also found some great new music in Athens, but I’ll leave that for another post.

Food
We actually did not pack much car food, just some fruit and cheese and pretzels and water and diet coke for me. We promised ourselves we would eat 3 squares and avoid road food, and we almost succeeded.

Maps
I love ’em, don’t you? The crinkling of the pages as you wrestle with them in the front seat with the wind tearing the edges from your hands…

Okay, we’re ready to go. Have I forgotten anything other than my pillow? What would you bring?

Next Up: The Road

Just Thinking (I do that sometimes…)

So, here’s what I’ve been thinking lately.

We all have to die, right? Really. We cannot live forever, even if we think we can.

So no matter how good we get at health care and taking care of ourselves, we are all going to die of something. And there will always be a “#1 killer of women” and a “#1 killer of men” for us to be afraid of.

And a cause to fight or a new drug to sell or a headline to scare us or funding that is needed from the government for treatment and research.

So when does it stop?

I mean, what happens when we’ve cured cancer and found the perfect statin or perfect diet? What will we do when the word “plaque” only refers to a thing you get to hang on your wall ? Or when diabetes is discovered to be from a virus and we get the vaccine, and when stem cells make Alzheimer’s and Parkinson’s obsolete…will there be anything left to die from?

Or will we all live forever?

And if we don’t live forever, how long will we all live? To 120 years old? 150?

At that point, will there be a group of people who are living to 150 and still look great but a whole lot of people will still be dying at 95 from heart disease because they can’t afford the best health care?


But that’s already happening, isn’t it? Just on an earlier scale.

I mean, here we are, just plowing ahead curing everything right and left, leaving many of us to live longer and longer while women and children are dying at young ages from thing like malaria, measles and infant diarrhea. Diseases we in the developed world left behind in the history books years ago.

Really, really think about that. While we sit here worrying about which statin to take because we won’t get off our fat ass to exercise, kids are dying all over Africa from malaria. And malnutrition.

That’s because there’s no master plan. There’s no prioritizing where the money is going on a worldwide basis.

Now I know those laisse faire capitalists out there are saying “Leave it alone. Let it evolve. It’s working, just not at the pace everyone wants it to. And not equally everywhere, but give it time. We’re figuring it out…”

But are we figuring it out? Or are we just figuring out best how to make money doing it?

Because if it’s really all about making money, then we should not be surprised that we spend so much on it. And we should all just shut up and spend the money and see where it takes us.

But we really don’t want to spend the money, do we? We want our cash for other things, like I-phones and HDTV and oil guzzling minivans and movie downloads.

Of course we can’t say that, so we talk about the uninsured and the poor who can’t afford health care.

But really, how much would it cost for us just to take care of those folks? Not much compared to what we are paying overall for health care we would rather get for free so we can spend our money elsewhere. And certainly pennies compared with the billions we spend trying to hang onto every last second of life because we really haven’t come to terms with the fact that we all have to die. And that if that death happens to be unexpected, it doesn’t necessarily mean that someone did something wrong and we have to find someone to blame.

How many times have I heard people speak these words – “Why haven’t they found the cause of … yet?” or “Someone has to have figured this out by now” or “”How come they don’t know …?”, all spoken with the expectation that it’s someone’s responsibility to have figured these things out, and if it’s not done, then by god, someone’s not doing their job!

All of which leads to lawsuits and raises the costs of health care even further.

Or do I have it all wrong? Maybe health care costs so much because the system isn’t free market enough. After all, the price of most things goes down with time – like I-Phones and laptops. But health care just keeps getting more expensive.

Maybe the answer is to just set the beast free. Get rid of insurance companies and go back to the days when folks just paid the doctor. Then who knows what health care would look like? Maybe I’d become obsolete because someone else has figured out how to deliver health care more cheaply.

Uh, oh. This though thought train is taking a turn I don’t like. I think I’ll stop now.

Apologies to Missouri

In my previous post, I trashed an entire state, and I apologize. Aparently, the differences in generic formularies between New York and Missouri are significant, and has led to the my confusion about what I can and cannot write to get a generic for my patient.

I’ve updated my prior post, and hope to stave off any nasty rumors about the show me state.

Missouri says "Show Me the Generic"

(This post has been updated to correct any misinformation in its previous version.)

Well, Missouri, the “Show Me” state, is living up to it’s name. You want to fill a prescription there? You want it to be generic? It has to be on their generic formulary.

Each state, you see, has it’s own generic substitution formulary, unless the generic subsitution has been mandated by the FDA. If a drug is on a state formulary, it can be substituted by the pharmacist as long as you don’t specify otherwise. If a generic exists, and it’s not on the state formulary, the physician has to ask for that generic by name.

Why should I care about Missouri’s formulary?

Because now that Aetna/US healthcare has bought a mail order pharmacy in Kansas City, I am told that the scripts I write for patients in that plan are being filled according to Missouri state formulary. Not a few drugs I frequently write that once were automatically substituted here do not have generics in Missouri. And my patients are getting hit with the difference.

I was asked by a patient today to rewrite all her scripts with specific generic names so she could mail them away. Otherwise, she would end up paying full price for the brand name, as had happened to her (and her husband) three months ago when they first filled scripts at Aetna’s new pharmacy. Surprise! Your former $20 copay drug is now $150. Already filled and deducted from your credit card, sorry.

It’s hard enough to keep track of my own state formulary, let alone those of the other 49 states where big insurers might want to buy a pharmacy. And now I have to keep track of the generics out there, and decide which generic I want to write if it’s not on a state’s formulary. (Not to mention the confusion and burden on my patients.)

I do not have the information needed to decide which generic I should write, do you? When it comes to oral contraceptives, multiple generics can exist for a single formulation. I can’t tell them apart. I write the brand name, and let the FDA and the pharmacist do the rest.

Maybe I’m too trusting. Maybe I should keep track of all the generics out there. Maybe I should care which generic my patient gets. But I don’t.

Am I wrong?

Union Pacific and Contraceptive Coverage – What’s Really Going On?

All right, I’m confused.

Union Pacific goes to a higher court to argue that they do not have to provide healthcare coverage for the cost of prescription contraceptives, and they win.

Than I read in the NY Times that the Union Pacific, which has been providing coverage for contraception since they lost the initial lower court case in 2005, does not intend to take the coverage away.

In July 2005, a federal district court in Nebraska ruled in favor of the plaintiffs and ordered Union Pacific to cover all prescription contraception approved by the Food and Drug Administration.

Under Thursday’s ruling, the company could end that coverage. But a spokesman for Union Pacific, the nation’s largest rail line with more than 50,000 workers, said yesterday that the coverage would continue.

“We’re not going to take it away,” the spokesman, Mark Davis, said. The ruling covers all of the railroad’s unionized female employees.

So what were they doing in court????

Addendum:

Okay, so I may have figured it out. Apparently after UP initially filed their appeal, collective bargaining between the railroads and the unions led to contraceptive coverage anyway, so they can’t back out on it now.

However the 8th Circuit ruling means that UP won’t have to pay the plaintiffs attornies’ fees or back contraceptive costs. Still, I can’t help but wonder who else was pushing them to continue their appeal on this one. It has such far reaching impact…