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”

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A recent study reported by the Detroit News shows that the average motorcycle claim since the motorcycle helmet law was rescinded increased from $5,410 to $7,257.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. . .

Another Letter to Washington, from a Physician on the Front Lines.

 -by Matthew Moeller.

Due to the tremendous popularity of Dr. Moeller’s original post as well as some of the critiques and questions it raised, Dr. Moeller has written this follow-up post in response.

Thank you to everyone for the positive feedback. Over 57,000 Facebook “likes”, tweets, and newspaper requests over the past week was quite a surprise. I was especially moved by the multiple tweets from hospices, physician groups, and individuals recommending my article. This article really has hit a nerve and shed light on some of the issues at hand in today’s healthcare debate. I am writing a follow up article to further address some issues.

First, I wrote my original letter to illustrate some sacrifices doctors on the front lines of care make. In order for doctors to continue providing the highest quality comprehensive care, we need our leaders/ lawmakers to understand the perspective we face so that the best solution can be found to care for our population. I do not feel that this particular perspective was voiced on Capitol Hill during the health care reform debate. Yes, there are lobbyists, but they are not those who are treating patients and may not know the nuances that individual doctors can provide. In addition, I am concerned about my colleagues in private practice (specialists or primary care doctors) whose livelihood is threatened because of the potential cuts in reimbursement (up to 26%). This measure could force these doctors out of practice simply because their expenses (which rise yearly) are exceeding their declining reimbursement, which has declined steadily over the past several years already. If this does happen, it may force doctors to stop seeing Medicare patients because reimbursement is usually lowest for this group. It will take away the physician-patient relationship that is needed for great medical care. A recent Forbes article explains this. In my opinion, Congress needs the help of doctors who take care of patients daily to give their advice on possible remedies.

Despite these lingering issues, I nevertheless love my profession and my patients. Becoming a doctor was the right choice for me; I was interested in science since I was a little kid and am thankful that I can use my education to help my patients and their families. I have also learned a tremendous amount from my patients. I cannot see myself practicing any other field other than medicine and I am humbled daily serving my patients. I definitely would do it all over again as well because I feel this profession is my calling and I get an enormous amount of personal satisfaction taking care of those in need. Anyways, who would go into medicine in the first place with its long hours, large debt load, delayed earnings, risk of lawsuits, and daily life and death decisions if they didn’t true care about the human race? I am happy to say that most of my colleagues feel the same way. Our concerns rest on the idea that we may not be able to provide quality care to all patients if the tools and resources we need are reduced.

Second, I was trying to speak for ALL doctors, not just GI doctors. People have commented that I was complaining about my salary and the salary of GI doctors. This article was not intended for GI physicians, but, rather, for all physicians. Not all physicians get paid the same and primary care doctors typically get paid significantly less than specialists. The article was a personal anecdote to illustrate some sacrifices of a typical doctor who is paying off his or her loans themselves. I am not complaining about my current compensation. Doctors do have the highest average salary of any other profession despite the financial sacrifices early in our career. But I am concerned about the FUTURE CUTS that may force doctors to

either stop seeing Medicare patients or encourage them to do concierge medicine (which charges a premium to patients for access to the doctor). I have this concern because most of my colleagues in practices have seen their reimbursement cut and their expenses increase. When these two things happen, one either works more hours in the week to make up the difference or their expenses increase until they can no longer afford to see patients without going into debt. This in turn could lead to the decline of quality advanced health care that Americans enjoy. There are numerous articles out there as well that show concierge medicine is growing). Continue reading “Another Letter to Washington, from a Physician on the Front Lines.”

An Open Letter to Washington, D.C. From a Physician on the Front Lines.

-by Matthew Moeller M.D.

I am writing this letter because I feel that our leaders and lawmakers do not have an accurate picture of what it actually entails to become a physician today; specifically, the financial, intellectual, social, mental, and physical demands of the profession. This is an opinion that is shared amongst many of my colleagues. Because of these concerns, I would like to personally relate my own story. My story discusses what it took to mold, educate, and train a young Midwestern boy from modest roots to become an outstanding physician, who is capable of taking care of any medical issues that may plague your own family, friends, or colleagues.

I grew up in the suburbs of southeast Michigan in a middle class family.  My father is an engineer at General Motors and my mother is a Catholic school administrator in my hometown. My family worked hard and sacrificed much to enroll me in a private Catholic elementary school in a small town in Michigan.  I thought I wanted to be a doctor in 5th grade based on my love of science and the idea of wanting to help others despite no extended family members involved in medicine.  Winning a science fair project about the circulatory system in 6th grade really piqued my interest in the field. Throughout high school, I took several science courses that again reinforced my interest and enthusiasm towards the field of medicine.  I then enrolled at Saint Louis University to advance my training for a total of eight years of intense education, including undergraduate and medical school.  The goal was to prepare myself to take care of sick patients and to save the lives of others (four years of undergraduate premedical studies and four years of medical school).  After graduation from medical school at age 26, I then pursued training in Internal Medicine at the University of Michigan, which was a three year program where I learned to manage complex problems associated with internal organs, including the heart, lungs, gastrointestinal tract, kidneys and others.  I then went on to pursue an additional 3 years of specialty medical training (fellowship) in the field of gastroenterology. The completion of that program culminated 14 years of post-high school education. It was as that point, at the tender age of 32 and searching for my first job, that I could say that my career in medicine began.

Over that 14 year time period of training, I, and many others like me, made tremendous sacrifices.  Only now as I sit with my laptop in the dead of night, with the sounds of my children sleeping, can I look back and see where my journey began.

For me, it began in college, taking rigorous pre-medical courses against a large yearly burden of tuition:  $27,000 of debt yearly for 4 years.  I was one of the fortunate ones. Because I excelled in a competitive academic environment in high school and was able to maintain a position in the top tier of my class, I obtained an academic scholarship, covering 70% of this tuition.  I was fortunate to have graduated from college with “only” $25,000 in student debt. Two weeks after finishing my undergraduate education, I began medical school.  After including books, various exams that would typically cost $1000-$3000 per test, and medical school tuition, my yearly education costs amounted to $45,000 per year. Unlike most other fields of study, the demands of medical school education, with daytime classes and night time studying, make it nearly impossible to hold down an extra source of income. I spent an additional $5000 in my final year for application fees and interview travel as I sought a residency position in Internal Medicine.  After being “matched” into a residency position in Michigan, I took out yet another $10,000 loan to relocate and pay for my final expenses in medical school, as moving expenses are not paid for by training programs.

At that point, with medical school completed, I was only halfway through my journey to becoming a doctor.  I recall a moment then, sitting with a group of students in a room with a financial adviser who was saying something about how to consolidate loans. I stared meekly at numbers on  a piece of paper listing what I owed for the 2 degrees that I had earned , knowing full well that I didn’t yet have the ability to earn a dime. I didn’t know whether to cry at the number or be happy that mine was lower than most of my friends. My number was $196,000. Continue reading “An Open Letter to Washington, D.C. From a Physician on the Front Lines.”

Coming Soon: Get Your Implantable Defibrillator on Craigslist?

Yes, I know I’m supposed to bring you the stunning conclusion to my top ten list of medical advances. But I was so excited to talk about this article I read recently that I’m bringing you this post instead. The top ten medical advances (1-5) will be up in 2 weeks. Unless I decide to bump it again.

We live in a golden age of technology and manufacturing. An age in which we’ve been spoiled by machines, personal devices and electronics have been created to ever increasing standards. Just a few decades ago, you couldn’t buy a Chevy Nova whose bumper didn’t fall off a week after you drove it off the lot. But today’s cars are engineered so well that they easily go hundred thousand miles and beyond.  Consumers expectations are now so high, that to ensure that electronics last the expected amount of time, they‘re engineered to last much longer than that. The cell phone(s) in your closet that you forgot about when you renewed your contract probably makes calls just as well as the one you’re using now.
The same goes for medical devices, particularly crucially important medical devices like implantable cardiac defibrillators (ICD). To ensure that they last the expected amount of time and deliver their life sustaining jolts, they have to be built to last. (For the amount of money they charge for them, they had better be). Unfortunately, building something like an implantable cardiac defibrillator to such exacting standards makes them extraordinarily expensive. Think your average Mercedes Benz expensive. And that significantly raises the bar for entry, particularly for the poor both in this country and abroad. In third world countries, access to such devices is limited to the super wealthy, as private insurance plans are limited and government resources are typically directed towards more elemental aspects of health that affect the larger population. In other words, in countries like India, if you’re fortunate enough to have lived long enough to have a cardiac problem which warrants the placement of a defibrillator, you had better be rich enough to afford one. If not, you’re on your own. Continue reading “Coming Soon: Get Your Implantable Defibrillator on Craigslist?”

Lung Cancer Screening: Almost There . . .

In 2011 The National Cancer Institute published results from their study of low dose CT lung cancer screening of individuals identified as at risk for lung cancer. The investigators enrolled those between 55 to 74 years of age who had at least 30 pack years of smoking under their belt (number of packs per day multiplied by number of years smoked). These people were then randomly assigned to either a chest x-ray group or a “low dose” CT scan group, with 3 images over 2 years. There was initial criticism that the authors used chest x-rays as the control rather than “usual care”. However given that the PLCO trial, comparing chest x-rays to usual care, subsequently showed no difference between the two, this would appear to have been a sound strategy.

The study also received some well deserved praise, as it was the largest study of its kind, and demonstrated some very impressive findings, as detailed in the article’s abstract. The most striking findings were:

  • a 20% reduction in the risk of death from cancer relative to the control group.
  • a 6.7% reduction in the risk of death from any cause relative to the control group.

I cannot sum up how to you how astounding these results were/are to the medical community, specifically to those who are involved as patients, or in the treatment, diagnosis, support, research, and  fund raising of lung cancer. Continue reading “Lung Cancer Screening: Almost There . . .”

Healthcare Armageddon 6: Medicare and Generation X

                                              I’m Talkin’ About My Generation.

**Update: Treasury has just issued its reports on Medicare and Social Security, the results making this article more timely and relevant than I had intended. Together SS and Medicare make up 36% of federal spending. The Social Security trust fund is predicted to run dry in 2033, while the Medicare hospital trust fund (for inpatient services) is slated for extinction in 2024. Link to the report here.


Over the past few months i have struggled with how to portray the recent changes coming down the pike for medicare, what with ACO’s, and  impending cuts due to mounting deficits and the ever increasing costs of medical care.  What viewpoint, I wondered,  should this blog take on these issues?
Should I take the role of the traditional physician-blogger, and share the viewpoint of the myriad other physicians around me who live with uncertainty about how to run their practices in the current fiscally deprived environment? Should I write about the constant worry about whether congress will extend the recurrent doc-fix or let the draconian cuts in reimbursements go through? Will I write about whether there will come a time when it will no longer be feasible to accept Medicare or Medicaid?

Continue reading “Healthcare Armageddon 6: Medicare and Generation X”

Snow Birds and The Unfulfilled Promise of Electronic Health Records.

Please enjoy this recycled oldie-but-goodie while I spend the next 6 weeks juggling a high case load with studying for the boards with taking care of two babies, etc. . .

The migration has begun. All over Michigan, the annual migration of flocks moving south is in full swing. And behind those flocks, the other annual Michigan migration is starting too. Our office is starting to see our winter ‘checkout’ patients before they migrate south for the winter.

Over the next month, I’ll see a multitude of patients come in to get ‘checked out’ and get paper prescriptions to take with them to Florida in case they find themselves under threat of missing a golf outing due to varying states of cougheyness and/or wheeziness. Many of them have physicians in Florida that they sometimes see, and occasionally they get hospitalized while down there. They usually come back with an impeccable tan, an extra spring in their step, and a story of their various physician visits and /or hospitalizations with more holes in it than your average disability application.  They also explain that any tests that I’m about to order have probably already been done by their physicians in Florida, and they’d like me to take a look at those records before I order anything. We then start the dance of trying to get copies of their charts, which goes something like this:

Records Requested:                                 Records Received:
Request for chart.                                                     Nothing                  

Second request.                                                       Nurses notes 

Third request..                                   Copy of diet recommendations.

This whole dance has started to make me wonder about my ardent support for the electronification of medical records, which is supposed to do for medical care what the invention of sliced bread did for a fledgling sliced deli meat industry. By now we’re all aware that the Institute of Medicine (which by the way, to me sounds like a made up name) tells us that a gazillion patients are unnecessarily being decapitated every day because physicians’ illegible orders for ‘allow decaf for patient’ are being misinterpreted by hapless nurses as ‘and now decapitation’. Electronic medical records, says the Institute, would successfully ameliorate the silent killer that is physician penmanship.
But how does this impact the care of patients who had treatment from another physician or medical system, whether it was across the country or across the street? Nada. If I want to see those high tech electronic records, it still requires that I talk to a person, those records must then be printed, then faxed. Because of this, many of these tests end up being duplicated, and because of the awesomeness/stupidness of medicare, it has continued to pay for the duplication of these tests even if it has only been days since the original tests were done.

It seems to me then, that adding electronic medical records to the current system is kinda like adding a microchip to an abacus. . . in the end all you get might be nothing more than a fantastically expensive Goldberg machine. To me the only way that electronification of medical records will ever be the revolution that it’s backers claim it will be, is when there is a high degree of compatibility between systems. This would allow patients’ data to be shared among multiple different records systems. It would provide patients greater mobility between medical systems, rather than being tied to whatever system their PCP happens to be in. That greater mobility in turn might place greater pricing pressure on different medical systems as they are forced to compete to a greater degree. So how exactly do we implement this? I don’t know. But I promise I’ll start thinking about it once I’m done faxing all these diet recommendations to Florida.

EMR and the Loss of Eloquence

Much has been made of the downside of the increasing use of EMR systems by physicians. But I am not going to  dwell on those pervasive complaints concerning the cost and complexity of setting up the systems. Nor shall I rehash the well known issue of what I call “doc blocking”. . . wherein a computer (or other entity) stands between the patient and physician, slowing the exchange of information to however many words can be typed per minute. No there’s another more pressing issue to me personally that is rarely discussed in regards to use of the EMR. The loss of eloquence. Continue reading “EMR and the Loss of Eloquence”