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Why I Stopped Working with Express Scripts

Mail order pharmacies like Express Scripts and Medco have become increasingly prominent players in health care. But these companies are a lot more than simply mail order pharmacies, they are in fact a new generation of pharmacy benefit managers (PBM’s). PBM’s are essentially middle-men between insurance and pharmacy, with companies like Express Scripts merging the dual functions of a PBM and pharmacist into one. PBM’s manage and administer medication benefits for insurance companies. The largest insurance companies contract with them not only to manage the medication benefits of their clients (that would be you), but also to contain costs. Since insurance companies are not in the business of directly managing pharmacy services themselves, they contract with PBM’s to coordinate and manage their patients’ insurance benefits for them. If a PBM can do that at a lower cost, they save (make) money for themselves and the insurance company.

Mail order pharmacies are in a unique position to do this, as they don’t have to maintain brick-and-mortar outlets, and can use the mail to reduce costs . With such an advantage in cost containment, mail order PBM’s are quickly pushing traditional brick and mortar outfits to the periphery (remember Netflix vs. Blockbuster?). Mail order pharmacies are thus becoming giants in this industry. In 2012, Express Scripts completed a $29 billion acquisition of Medco, to create the country’s largest PBM, a publicly traded company with $100 billion in annual revenue. Continue reading “Why I Stopped Working with Express Scripts”

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Infographic: 10 Revolutionary Medical Advancements on the Horizon.

I’ve said it never and I’ll say it again: Ya gotta love infographics! How else could you turn an otherwise random and often sleep-inducing jumble of important looking illustrations and maybe facts into an eye catching array that draws you in like a fly to a plasma screen? So compelling, their like the pop-up books of science.  Such an obvious idea, right? Yet their still new enough to set off your spell check. (Go ahead, open up Word. I’ll wait. See?)

So I was joyed to accept an invitation to post Caduceusblog’s first-ever infographic. Thanks to the graphic smiths at Master’s in Health Administration Degrees for submitting this post (even if they are a bit numerically challenged;). You can see the original post here

Continue reading “Infographic: 10 Revolutionary Medical Advancements on the Horizon.”

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Smartphone App Allows COPD Patients to Individualize Their Care.

Health-care technology advocates have long been preaching about the potential of smartphones and other types of disruptive technology to improve health-care delivery. We in organized medicine have been slow to answer the call. Studies that showcase the ability of these tools in major medical journals are rare.  However, in a recent issue of CHEST, we see a welcome addition to the medical literature.

In this study,  researchers taught patients with COPD to create daily symptom diaries on smartphones (BlackBerry 8700s).  The results were uploaded to a research server and the program alerted staff when certain predetermined criteria were met. Using the data, researchers were able to accurately and quickly identify patients who were having an exacerbation of their COPD. They were also able to collect data on both the timing and length of the exacerbation.

This has exciting implications. Perhaps this kind of patient centered  data could be used to identify patients with severe symptoms and prevent hospitalizations, or to serve as a measure of response in clinical trials to various interterventions. The possible applications are numerous.

Though there is one aspect of this study that, as a tech geek, leaves me ambivalent. Should I be excited that even an obsolete smartphone could prove to be so useful? Or depressed that even an obsolete smartphone is so far ahead of current medical technology?

How do you feel about patient-centered smartphone apps that allow patients to individualize their care?

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This article is also posted at the ACCP Thought Leaders Blog.

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The War Is Not Over: PTSD Common Among ICU Survivors.

The ICU is a terrifying place. The noise, the alarms, the invasive tubes and wires, and the loss of control all contribute to an overall feeling of anxiety and stress in patients and in families. Add to that the emotional burden of being ill or having a sick family member or friend, and you have a perfect storm for the development of post traumatic stress disorder.

As a health-care provider working in the ICU, it is easy to forget how desensitized we are to this environment. Recently, I took a phone call from my wife (who is a nonmedical professional) in the ICU. After a few minutes, she asked in a panicked voice, “Do you need to go get that alarm”?! And of course, it was a “first-level” alarm that I had completely tuned out and hadn’t even noticed. Looking around the ICU as I write this, I’m certain that I’m not the only one who is numb to these stimuli.

In a recent issue of CHEST, Dr. Bienvenu and colleagues report the findings of a study looking at posttraumatic stress disorder in the survivors of acute lung injury. They interviewed 60 survivors of acute lung injury 1 to 5 years after their hospitalizations. The authors compared a self-reported screening tool and a clinician-administered tool. They found that 27% of patients in this cohort had PTSD or partial PTSD, and that the self-reported screening tool was a reliable method of assessing PTSD in this population. This is promising, since a self-reported tool can gain more widespread use and may be able to help future investigators better determine factors associated with the development of PTSD in the ICU survivors.

Determining who would be likely to develop PTSD would be an important advance in critical care. Often I think we are surprised at how even our “good” outcomes can have long-standing functional problems following their ICU course. In the perfectly titled accompanying editorial Surviving the ICU Does Not Mean That the War Is Over, Dr. Schelling tells the story of one patient who survived extracorporeal membrane oxygenation (ECMO) only to report horrific memories of scenes from an apocalyptic warfare. These memories significantly impacted his quality of life and functional recovery, even though his overall outcome was “good.”

These studies add to the growing literature about the long-term effects of our treatments. I’d be eager to see more. We do not consider this important area of quality enough. With studies like this to help give us better tools, hopefully we will see more investigations into the long-term impacts of the life-saving therapies we provide.

Chris Carroll, MD, FCCP is a Pediatric Intensivist at Connecticut Children’s Medical Center, and my Social Media co-editor at Chest Journal. He is on twitter @ChrisCarrollMD. Be sure to check out our posts at the ACCP Thought Leaders Blog, where this article  was originally posted.

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What You Need to Know About Electronic Cigarettes

Electronic cigarettes are here, settling over the country, quite literally,  like a fine white fog.  Smokers in turn, have been turning to them as a tool to help them quit, though the device manufacturers are are not allowed to market them that way in U.S. It seems intuitive that a device that mimics the action of smoking but without the combustion and smell of burned nicotine would be an ideal nicotine replacement therapy. However, there remain precious little research about weather the fine white smoke they deliver is as harmless as a morning fog, or as dangerous (and unwatchable) as an Oregonian fog delivering the vengeance of tormented souls.

E-cigs’ popularity can be attributed to the fact that they deliver an experience that very closely mimics the act of smoking, minus the social banishment that comes with exhaling obnoxious smelling carcinogens into other people’s personal space. How do they accomplish this seemingly impossible task? Why through the magic of modern technology, of course!

E-cigs look much like a regular cigarette, they are puffed on in the same way, give off a vapor that looks like smoke and even have an LED light that mimics the combustion of nicotine. The devices are made up of several components. In place of the body of the traditional cigarette, there sits a rechargeable battery housed within a cartridge which is capped on its end by an LED light. Where the filter would usually be on a traditional cigarette, there sits  a heating element/atomizer as well as a replaceable nicotine cartridge. It is within this cartridge where a liquid mixture of nicotine, flavoring, and propylene glycol sits. Propylene glycol is a food additive that is also  used to create the “fog” in fog machines. The cartridges can be obtained in varying strengths of nicotine all the way down to zero.

When one puffs on an e-cig, the sensor activates the LED and the heating element which then atomizes the fluid in the cartridge, delivering a dose of nicotine and vapor. The main perceived safety advantage of this mode of nicotine delivery has presumed to be the lack of combustion of nicotine, which by itself creates a host of toxic chemicals. The nicotine itself is still delivered, however, with its resultant deleterious effects.

There remain a number of things which are not well known about e-cigs. While propylene glycol appears to be safe in other applications (it’s an FDA approved food additive), it is uncertain as to how inhaling it regularly affects the lungs.  It is also uncertain how efficacious e-cigs are when used the way that many people appear to be using them, as a smoking cessation tool.

To that end researchers in Italy conducted a study in which they enrolled 300 smokers who were not interested in quitting and were otherwise healthy. They were randomized to using e-cigs at either a steady dose of nicotine, a decreasing dose, or containing no nicotine at all for 12 weeks. They were allowed to use the e-cigs as they liked in addition to regular smoking and they were not  encouraged to quit smoking regular cigarettes.  After 1 year, quit rates (for all nicotine including e-cigs) among those using nicotine containing e-cigs were 11%. While this may not seem like a lot, it is as good as or better than most current nicotine replacement therapies. Keep in mind that these were people who were casually smoking e-cigs without the intention of quitting. Among those who did not quit, the number of cigarettes smoked daily decreased from 21 smoked per day to 14.

The investigators also looked at adverse events in order to gauge safety. They found that commonly reported adverse events actually decreased from baseline over the course of the study. They also found that side effects commonly seen during  smoking cessation trials such as hunger, insomnia, irritability and depression, were infrequent, nor were there any significant changes in weight.

This data appears encouraging that e-cigs do have some use as a nicotine replacement therapy, and that many people could actually quit without simply exchanging one addiction for another. It also appeared that, at least over the duration of the study, the e-cigs appeared safe. People appeared to have less side effects, probably owing to the fact that they were smoking fewer traditional cigarettes.

However, this short 12 week study can not tell us about long term effects of e-cigs. Nor does it address other pertinent questions. Such as the moral hazard of removing social stigmas. Many who use e-cigs do so with the thought that they can use them in places where regular smoking is not allowed.  One could wonder whether these products could take us back to the days of Don Draper,  when it was permissible to smoke in public places, or even on the job, unwittingly leading to greater smoking rates. Some argue that the ability to flavor e-cigs will further draw younger people to smoke, likely made worse by an incorrect perception that, since they are not cigarettes,  e-cigs are “safe”. Yet another problem is the consistency between products themselves. There exists a significant variation between contents of e-cigs between different makers, making it difficult to judge whether findings about one product can be generalized to others.

Indeed, we are only at the beginning of determining the risks and benefits of e-cigarettes. While they do appear to have some promise as cigarette smoking cessation tools, there remain several hazards to their increasing use. Until we have a better idea of what exactly is in this increasing fog, we best proceed with caution.

Citation: Caponnetto P, Campagna D, Cibella F, Morjaria JB, Caruso M, et al. (2013) EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as Tobacco Cigarettes A Prospective 12-Month Randomized Control Design Study. PLoS ONE 8(6): e66317. doi:10.1371/journal.pone.0066317

 

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“When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians.

 

This article was written by a Pulmonary, Critical Care Fellow who completed residency after recent resident duty hour restrictions went into effect.

During my internal medicine residency, we were allowed to work  a maximum of 30 hours per shift.  You would do a 24 hour call in the hospital , then round on your patients post-call and go home by noon.  This was the norm.  I completed 5-6 of these shifts per month during my entire 3 years of residency.  Even then, when timidly telling my attending physicians that it was time for me to go home after fulfilling my 30 hours of duty and barely being able to keep my eyes open, they would respond with the old clichéd phrase “Well, when I was a resident……”  The sentence would usually end with something about how they used to work for 3 days straight with no sleep, no shower, and on and on.  Just like your Dad telling you “When I was a kid, I would walk to school, barefoot, in 6 feet of snow…..uphill.” At least that’s what my Dad would say, and I would sigh and roll my eyes.    I never thought I would agree with such a cliché.  But now, as a 2nd year Pulmonary and Critical Care fellow, I frequently find myself repeating these same exact words:  “When I was a resident..” and let’s face it, that was only 2 years ago.

 I completed my residency  prior to the “new” duty hour limitations that went into effect in 2011.  The new regulations limit residents from working more than 16 hours straight; after 16 hours, they must have a mandatory “nap” time.   This has forced many institutions to change the call schedule to so-called “block nights”.  Residents are only allowed to work 12 hours during a call shift.  They work 12 hours and may stay for an additional 1-2 hours after for educational lectures and sign-out, but otherwise, they are off duty.  I have even found that many resident physicians will not even return a page after 7 am because apparently that would be a violation of duty hours.

 Shortening duty hours to a maximum of 16 hours at a time has not, in my opinion, improved resident physicians experience in any surmountable way.  It seems detrimental if anything.  Studies including the one recently published in JAMA, would seem to support the view that shortened hours may not in fact be beneficial to residents or their patients.

Because of the changes in work hours, residents are becoming less educated, less experienced, and more apt to push work off onto someone else or to leave it altogether.  They have a decreasing sense of patient responsibility and motivation.   I frequently hear, “Oh, I have to leave, can’t go over my duty hours,” even when there is still patient care to be done.  I’m not asking that residents be asked to stay beyond what’s reasonable (and I know “reasonable” is still the big debate), but I do think these increased restrictions on allotted time in the hospital are molding a generation of residents who are less than motivated. Many are being  instilling with bad habits and a poor work ethic.

Now, I know, maybe I am just one of those people. The overachiever who expects a lot from myself, and from others.  I am, after all, a pulmonary/critical care fellow, so I do have that type of personality.  But I know the majority of my colleagues agree with me:  the general consensus is that these duty hour restrictions are instilling a lackadaisical apathy in many of the underclassman.  Not all, but many.  We are teaching them that it’s OK to do the minimum, and that there’s not a need to go above and beyond.  It’s OK that you weren’t able to put that arterial line in because you put in your 12 hours, and I know you were busy.

In my opinion, this is not acceptable. Continue reading ““When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians.”

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5 Things No One Taught Me in Residency

Below is a Repost of a previous article, that is appropriate to this time of year.

Since medical school, I’ve gone through an additional 6 years of training, read countless volumes of medical literature, and had the fortune of having some great teachers. Through it all, experience has been the greatest teacher, which I suppose is what training is about. I’ve watched with interest as advice has been hashed out on the web around this time of year to new trainees on all matter of subjects. And much of it is good and useful, to be sure.
Being the helpful person that I am, I naturally want to do my part. What, I thought, could I contribute to this discussion that hasn’t been said already?
To that end I’ve come up with my own list of of trivial and only slightly helpful tidbits of information, based on my own experiences over the last 11 years post graduation. Here I give you my top 5 list of things that no one ever told me in medical training. . .but should have. Enjoy.

1. Before conducting a family meeting, go the restroom. Scan your face for things that might appear distracting or unseemly,  like nasal boogies or lettuce stuck in your teeth, and quickly remove them. If you are one of the few convertible drivers with hair, pay special attention to this area; the “mad scientist” look is generally not one which inspires confidence in these situations.

2. Using hospital Jello-O and graham crackers as the base of your food pyramid makes for a reasonably strong pyramid.  At least as  strong as any other pyramid that has a soft mushy substance at its base.

3. Sometimes an appropriately discharged patient will refuse to leave the hospital. Follow your hospital’s policy in these situations. If it is your hospital’s policy to call security, then do so. However it would be wise to have your patient fill out the house officer rating/feedback form before doing so.

4. If your attending physician gives you an answer that seems wishy-washy, it’s because they don’t know the answer. They still know a heck of a lot more than you, though.

5. When entering a room to declare death on a patient, whose family is in the room, make sure your pager is on vibrate. Particularly remember to silence any cutesy ring tones (such as Cee Lo Green or the Benny Hill theme) that might bring unwanted awkwardness to an otherwise somber moment.

Thank you and Good Luck!

Related Posts: Be Nice to Nurses. . . Of Else!;   Where Medical Report Go to Die;  Top 5 OTC Meds that would require a prescription if released today;

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A Simple Test Can Determine Prognosis in Idiopathic Pulmonary Fibrosis

Sometimes it’s the simplest things that can make all the difference. Unfortunately, when it comes to informing patients with a new diagnosis of pulmonary fibrosis what to expect, things are anything but simple.  For years, pulmonologist, myself included, have dreaded the moment when we inform patients of a diagnosis of pulmonary fibrosis. The discussion invariably involves informing them  that this disease (which they have probably never heard of) may either kill them or have minimal effect on their lives, or have a moderate effect. Alternatively, it may have very little effect at first, but then suddenly become much worse. How can we tell which of these courses the person can expect? Well, we’re not really sure, we’ll just have to wait and see what happens.

To this day, I remain amazed at the stoicism and strength  that the  person who is sitting across from me accepts this information.  For these people there exists neither a good prognostic tool nor an effective treatment. One would think that for such a stark disease there would be 10K runs, gala fundraising dinners, and a powerful Washington lobby.

But there isn’t.

There is no nationwide clamor for research dollars. No push “for the cure” or even for any effective treatment. No distinctive ribbon clad awareness week (ok there is, but I bet you’ve never heard of it).

So it is with a great sense of excitement that we greet any new research which hints at the possibility that we can more accurately  tell our patients with this disease what they might expect in terms of prognosis. Such was the case as I read through a recent issue of Chest.

Researchers at Inova Fairfax Hospital in Falls Church, Virginia looked at the possibility of using the red cell distribution width (RDW) as a prognostic measure in patients with pulmonary fibrosis. The RDW is a blood test which measures variability in sizes of circulating red cells. The test is inexpensive, and usually drawn (and often ignored) as part of a complete blood count. Physicians who order a CBC usually pay attention to the hemoglobin, white blood cell and platelet counts, and hardly ever give the RDW a second glance.

But perhaps we should.

As variability in the size of red blood cells as measured by the RDW can tell us about pathological inflammation. The RDW has already found some use in helping with prognosis in people with Pulmonary Hypertension and Congestive Heart Failure, so why not Pulmonary Fibrosis?

In this study, they found that people who had a RDW of less than 15 had a median survival of 43 months, whereas those who had a RDW of greater than 15 had a median survival  of only 16 months. Survival appeared to be worse in those with even higher levels of RDW, and also appeared better in those with much lower levels. They also found that survival worsened in those individuals in whom the RDW increased by more than 0.01 per month on average.

Truly the idea of using a simple method to help determine the prognosis of patients with pulmonary fibrosis is exciting. Now if only we could find an equally simple method of improving that prognosis.

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Flash Mob Medical Research

It was my second day of residency, and something was afoot. As I made my way around my first rotation on the cardiac floor, my medical senses were tingling. There was something strange happening to all of my patients, I saw. As I peaked over my cohort’s shoulders, I secretly saw that it was happening to their patients too, though they hadn’t seemed to  notice. Only I did, and I was going to report it to my senior. Together we were going to report it to the New England Journal of Medicine, and I was going to win the Nobel Prize of Awesome Doctor. Yes, I alone noticed that all of the patients on the floor were somehow inexplicably breathing at the exact same respiratory rate. Not only this, but they were breathing fast, at a rate of 20, clearly something must be causing all of them to do this. Surely this could not have been due to documentation error, since all the of the other vital signs seemed to vary, it was only the respiratory rates which seemed to stay the same among all the patients.

 That day was more than 10 years distant, I still don’t have my nobel prize, and New England Journal isn’t returning my calls. The answer to the question that I posed back then about a phenomenon I now see daily is only too easy to find. It sits in every hospital ward, at the end of the hallway. There a  bank of mobile machines that is wheeled around the ward to check vital signs sits recharging in wall outlets. As nurses and assistants scramble to administer medications, change bedsheets, turn patients, answer call lights, help patients around the halls, answer the phones, answer family questions, speak with clinicians, and pass food trays, they wheel these devices to their patients’ bedside. They quickly first attach a blood pressure cuff and press the cycle button. As the cuff inflates, they attach a finger sat monitor from the same machine  which takes a few seconds to get a reading. As this is taking a reading, they ask the patient to open their mouth and insert a temperature probe to get a temperature. Around this time, the BP cuff says “error”, so they cycle it once more. While this cycles, they now have a reading for temperature, and the finger monitor gives them readings for oxygen saturation and heart rate.

They have a few paper towels left over from feeding the patient in the next bed, so they start jotting down numbers in it, and just as they finish this, they get a reading from the BP cuff, which they write down as well. They would like to put this in the computer right away, but in the hallway call light buzzers are sounding, somebody wants to get up. Another person wants their pain medications, the radiology suite wants the patient in the next bed sent for their ultrasound immediately.  But wait aren’t they supposed to be fasting for that test? And there’s 4 more patients who need to have their vital signs checked.

So several moments later, as the nurse finally sits down to enter all the vital signs into the chart, values will be entered for heart rate, blood pressure, temperature, oxygen saturation. But since no respiratory rate was checked, the default number of 18 or 20 is often entered. Why is the respiratory rate not checked?

Because the Mr. Vital Signs machine does not check respiratory rate. Continue reading “Flash Mob Medical Research”

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Motorcycle Accident Medical Claims Increase After Michigan Rescinds Helmet Law.

I wrote last year about the Michigan Legislature’s bold move to help improve the chances of people waiting to receive an organ transplant (see article here). As I discussed in that article, motorcycle riders are among the best organ donors, because they tend to be young and otherwise healthy.  A recent insurance industry study found that after only one year, the push to increase organ donation may be paying off.

A recent study reported by the Detroit News shows that the average motorcycle claim since the motorcycle helmet law was rescinded increased from $5,410 to $7,257. After adjusting for confounders and data from surrounding states, the increase was 22 percent. An increase in claims of course does not translate to an increase in the number of donor organs. Perhaps we need another law asking that motorcycle riders also indicate their organ donor status. . .