In my previous post, I showed a powerful picture (from the Kaiser Family Foundation) of the growth in high deductible insurance plans. Here is another picture from that same report, showing that the high end of these high ends is getting really high.
With health care costs rising, employers (and insurance companies) are increasingly asking consumers (aka “patients”) to have more “skin in the game”—to pay more out of pocket for their medical care. The Kaiser Family Foundation has a nice report on trends in health insurance deductibles. This picture shows the rise in these deductibles. That means: you pay a lot of money before insurance kicks in. All the more reason that we physicians need to talk, more openly, with our patients about the cost of care.
In her deservedly best-selling book, The Immortal Life of Henrietta Lacks, Rebecca Skloot reproduces the language of Lacks’s informed consent document when she was about to undergoing her cancer surgery at Johns Hopkins in 1951:
I hereby give consent to the staff of the Johns Hopkins Hospital to perform any operative procedures and under any anesthetic either local or general that they may deem necessary in the proper surgical care and treatment of _______________.
Talk about giving doctors leeway!
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Here is a link to a podcast of my recent appearance on People’s Pharmacy, an NPR show that hopefully reaches you where you live. (If it doesn’t, you should ask your radio station to pick it up. It is a great show.) In this podcast, Joe and Terry lead me on a wide ranging conversation, mainly but not exclusively about Critical Decisions.
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Since the recession hit hard a few years ago, health care expenditures have slowed dramatically. It now looks like, at least for medications, cost increases are making a comeback. For instance:
Nexium, a heartburn drug, had a 7.8% price hike to a $262 average prescription in the first nine months of 2012.
Enough to make your stomach hurt, yes?
According to the Bureau of Economic Analysis, medication prices rose 3.6% in 2012, twice the 1.7% inflation rate. One year does not a trend make. And the pharmaceutical industry is under a ton of pressure. Many of their best selling products have gone, or soon will go, generic. Even Nexium, which isn’t generic, faces stiff competition from generics that are just as effective for most people. That said, it is a good idea to find out how much your pills cost before you take them and, more importantly, find out if there are more affordable alternatives.
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Andrews was easily the most anxious patient I took care of that month, a gray Michigan February (is there any other kind?) which I spent in the hospital caring for patients admitted to the general medical ward at the Ann Arbor Veterans Affairs Medical Center. (Andrews is a pseudonym, as are all the patients I blog about, unless otherwise indicated.) He had plenty to be anxious about, too. His leukemia was raging out of control, his blood looking like pus, teeming as it was with malignant white blood cells. At his age—he was almost 60—and after a decade of chronic bone marrow cancer, his disease was especially dangerous. Odds were high he would survive for less than a year.
Unless . . . ! Unless the genetics of his cancer were favorable, indicating a good likelihood that he would respond to chemotherapy. So Andrews and I (and the rest of my general medicine team) waited to hear back from the oncologists about the result of his genetic studies.
Andrews wasn’t afraid of dying, because he’d already had a first-hand view of death at its worst. Twenty years earlier, he was working as a card dealer in Vegas and had fallen in love with another dealer. In the open-minded culture of that city… (Read more and view comments at Forbes)
“Revolutions are often fought over dichotomies—the king versus the people, the bourgeoisie versus the proletariat, and, of course, the autonomous patient versus the paternalistic doctor.” So observes Peter Ubel in the conclusion of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.
Who decides? Doctor or patient? For decades, too many of the advocates who have tangled with the establishment to empower patients have acted as though there is only black and white. The patient decides, not the doctor. The result has been a toxic standoff.
By throwing the dichotomy under the bus, Ubel takes a crucial step forward. Patients and doctors must work together to get to the right decision. The much tougher questions follow: How? What are the rules of engagement? How should the interaction proceed? Who does what?
Ubel’s expert dissection of the hidden complexities of these questions is thorough and impressive. In addition, Ubel is quite evidently a gifted writer,thinker, and communicator. Critical Decisions is a first-rate effort to popularize the science of medical decision making. Some readers will devour this book;in fact, researchers in the medical decision-making community might finish itin a single sitting. And general readers with an intellectual interest in healthcare—those who eagerly anticipate Atul Gawande’s next New Yorker article…(Read more at Health Affairs)
I got an email recently from someone who read Critical Decisions, and who said it resonated with her in part because of work she does with a breast cancer hot line.
“I’ve been volunteering as a Helpline worker for Living Beyond Breast Cancer. We get a lot of calls from women who seem to have communication problems with their doctors. Sometimes they don’t understand aspects of their treatment or are puzzled by unexpected side effects or think they’ll be seen as complainers if they speak up. We always tell them it’s part of their doctors’ jobs to answer questions and explain stuff, and we try to give them some information about what they’re experiencing to help them formulate questions. But your book also made me think it would be a good idea to help them articulate their values and priorities.”
My advice: Write down your questions in advance. And bring someone along to the visit, if possible, who is not shy about asserting themselves in front of doctors.
Any other suggestions you would have her pass along to the women calling in?
The first test tube baby was born July 25th, 1978 in the north of England. Louise Brown was called the “baby of the century” by some and a “moral abomination” by others. It wasn’t Brown who critics accused of being immoral, of course. She was just a blameless infant. Instead, it was her doctors who came under fire for their new fertility treatment—in vitro fertilization (or IVF). Roman Catholic theologians characterized this treatment as “unnatural”. Bioethicists fretted about the risk such treatments posed for mothers and children.
But all these critics of IVF missed the true immorality behind Louise Brown’s birth. Brown’s doctors never told her mother that IVF was a brand new procedure… (Read more and view comments at Forbes)
As if being diagnosed with breast cancer wasn’t bad enough, many women with this diagnosis face complicated decisions about what kind of medicine or chemotherapy to take, if any, to reduce their chance of cancer recurrence. As I discussed in a recent post, the mathematics of such decisions can be hard to comprehend for many patients. But given that the right choice often depends on patient preferences, it would be great to help patients understand enough of their math to involve them in making the choice.
A group of researchers has developed a tool to help women with these decisions. Called Adjuvant Online, it is a computer algorithm that takes in information about a specific woman’s cancer, and then produces survival estimates for her, illustrating her chance of survival and breast cancer recurrence based upon whether she chooses one set of treatments versus another… (Read more and view comments at Forbes)
